Clinical Quiz in Emergency Medicine

Clinical Quiz in Emergency Medicine

SHEK Kam Chuen
KAM Chak Wah
Copyright Date: 2007
Pages: 180
https://www.jstor.org/stable/j.ctt1xwb0r
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  • Book Info
    Clinical Quiz in Emergency Medicine
    Book Description:

    Written by emergency medicine specialists in Hong Kong, this book consists of 70 real cases encountered in an emergency department. Short history, clinical pictures, ECGs, X-rays, CT scans and ultrasound images are included and clinical questions are set from the emergency medicine perspective. Detailed answers are provided with references. The book is intended for medical personnel working in emergency departments. Senior EM specialists would also find the cases and discussion refreshing and pertinent for updating their existing knowledge. Most of the cases are written according to the required standard of precision for international fellowship examinations.

    eISBN: 978-988-8052-12-7
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-viii)
  3. Preface
    (pp. ix-ix)
    Shek Kam Chuen and Kam Chak Wah
  4. Acknowledgements
    (pp. x-x)
    Shek Kam Chuen and Kam Chak Wah
  5. About the authors
    (pp. xi-xi)
  6. Abbreviations and symbols
    (pp. xii-1)
  7. 1 A 60-year-old man with severe interscapular back pain
    (pp. 2-3)

    A 60-year-old man presented to ED because of sudden onset of severe interscapular back pain that he had experienced for one hour. A CXR revealed a widened mediastinum. An urgent CT thorax was performed.

    1. What are the CT findings?

    2. What is the diagnosis?

    3. What might the CXR show (in addition to widened mediastinum)?

    4. What are two classifications of the above diagnosis?

    1. There is an intimal flap separating the true lumen and false lumen. Both ascending and descending aorta are involved. The true lumen is markedly narrow and is close to the inner curvature of the...

  8. 2 A 13-year-old boy with chin injury
    (pp. 4-6)

    A 13-year-old boy fell from a motorcycle in China one day before presenting to ED. He suffered from chin injury and found difficulty opening his mouth. An X-ray of the mandible was taken.

    1. What is the X-ray diagnosis?

    2. What are the symptoms and signs of the above diagnosis?

    3. What other X-ray views are useful in assessing the above diagnosis?

    4. What is the ED treatment?

    The PA X-ray of the mandible reveals bilateral fractures of the body of the mandible — the most frequent site of fracture. The condylar region, the angle and the symphysis are in...

  9. 3 A 40-year-old woman with cat-bite wound
    (pp. 7-9)

    A 40-year-old woman had been bitten on her right hand by her cat. The following day she presented to ED because of increased pain and swelling of the hand. There was purulent discharge from the wound.

    1. What is the most likely offending organism?

    2. What antimicrobial agent should be given?

    3. What is the difference between the nature of dog- and catbite wounds?

    4. If a patient presents with fever and septicaemia after a dog bite, what is the likely offending organism?

    5. What is the causative organism of cat-scratch disease?

    1. The most likely offending organism is Pasteurella...

  10. 4 A 12-year-old girl with left ankle sprain
    (pp. 10-11)

    A 12-year-old girl sprained her left ankle while running. She presented to ED. Pain and swelling at the lower end of the left tibia were noted. An X-ray of ankle was taken.

    1. Where are the X-ray findings?

    2. Which type of fracture is this?

    3. What is the specific name for this fracture?

    4. What would the fracture be called if metaphysis of the tibia were also involved?

    5. What is the treatment of choice?

    1. A vertical radiolucent line is seen extending through the epiphysis of the left tibia to enter the growth plate, then transversely across the...

  11. 5 A 28-year-old man with left eye pain
    (pp. 12-13)

    A 28-year-old man presented to ED with a painful red left eye that he had experienced for one day. He was a contact lens user. The eye was stained with fluorescein.

    1. What are the clinical findings?

    2. What is the likely offending organism?

    3. What is the treatment?

    4. If the patient had presented in early 2006, what special fungal organism would have been the possible cause?

    1. There is a large, central corneal ulcer over the left eye. There is also an injected conjunctiva. The presence of hypopyon (a layer of white blood cells in the lower part...

  12. 6 A 45-year-old man with painful swollen right thigh
    (pp. 14-15)

    A 45-year-old man presented to ED with a painful swollen right thigh that he had experienced for two days. There was no history of injury, and he was afebrile. A blood culture was taken and smears revealed Gram-positive cocci and later confirmed Streptococcus pyogenes.

    1. What is the diagnosis?

    2. What are two types of the above diagnosis and the causative organisms of each type?

    3. How could ultrasonography be used to differentiate the above diagnosis from cellulitis?

    1. The diagnosis is necrotizing fasciitis.

    2. Necrotizing fasciitis traditionally is classified into two types. Type I is polymicrobial and typically caused...

  13. 7 A 60-year-old woman with shortness of breath and fever
    (pp. 16-17)

    A 60-year-old woman complained of acute onset of SOB and a fever of 38°C. Her BP was 120/60 mmHg and pulse was 120/min. She had tachypnea. The pulse oximetry was 93% on room air. A CXR was taken.

    1. What is the X-ray finding?

    2. What is the diagnosis?

    3. Name the two types of the above diagnosis?

    4. What is the mostly likely cause of fever and SOB?

    5. What is the urgent ED procedure that may relieve SOB?

    1. There is a cavity with fluid in the mediastinum behind the heart.

    2. The diagnosis is hiatus hernia. The...

  14. 8 An 18-year-old young man with shortness of breath and dizziness
    (pp. 18-19)

    An 18-year-old young man presented to ED because of SOB and dizziness after being stung by an insect as shown. His BP was 80/40 mmHg and pulse was 120/min. There was diffuse erythema and some urticaria over his body.

    1. What is the clinical diagnosis?

    2. What is the offending insect?

    3. What are common precipitants of the above diagnosis?

    4. What is the ED treatment?

    5. What additional therapy may be useful if the patient concurrently is on a ß-blocker?

    1. The clinical diagnosis is anaphylactic shock. It is a manifestation of immediate hypersensitivity when a sensitized individual is...

  15. 9 A 50-year-old man with persistent headache and dizziness
    (pp. 20-21)

    A 50-year-old man presented to ED, complaining of persistent headache and dizziness that he had experienced for two days. He denied any history of head injury. He was afebrile. An urgent CT scan of brain was performed.

    1. What are the CT findings?

    2. What is the clinical diagnosis?

    3. What are the risk factors for the above diagnosis?

    4. What should be the definitive treatment?

    1. There is extensive right crescent-shaped subdural effusion with some hyperdense component, compatible with acute on chronic haematoma. There is a mild midline shift towards the left side. There is no skull vault fracture...

  16. 10 A 25-year-old man with syncope
    (pp. 22-23)

    A 25-year-old man presented to ED because of experiencing syncope for 30 seconds. He had no convulsions. The neurological examination was normal. An ECG was performed.

    1. What are the ECG findings?

    2. What is the diagnosis?

    3. How should the diagnosis be confirmed?

    4. What should be the definitive treatment?

    5. What are other important ECG features for evaluating patients with syncope?

    1. The ECG shows incomplete RBBB and saddleback-shaped ST elevation over the V1–V2.

    2. The diagnosis is Brugada syndrome. In 1992, Pedro and Josep Brugada first described eight patients with sudden and aborted cardiac death; these...

  17. 11 A 12-year-old boy with left hip pain
    (pp. 24-26)

    A 12-year-old boy presented to ED because of having left hip pain for two weeks. An X-ray of the pelvis was taken.

    1. What are the X-ray findings?

    2. What is the clinical diagnosis?

    3. What X-ray view is indicated to determine the diagnosis?

    What findings will this show?

    4. What are signs in physical examination?

    5. What are the complications?

    6. What is the definitive treatment?

    1. There is an abnormal Trethowan sign on the left hip. A line (line of Klein) drawn along the superior border of the femoral neck should normally cut though the epiphysis. Shenton’s line...

  18. 12 A 50-year-old man with neck injury
    (pp. 27-29)

    A 50-year-old man presented to ED complaining of neck pain and weakness in four limbs after slipping and falling at home. A lateral cervical spine X-ray was taken.

    1. What are the four lines used to assess the alignment of the cervical spine?

    2. What is the X-ray diagnosis?

    3. An orthopaedics surgeon was consulted, and he suggested steroid therapy for the spinal injury. What are the contraindications for steroid therapy?

    4. If the patient develops hypotension, what would be the management?

    1. The four lines used to assess the alignment of the cervical spine are the following:

    anterior spinal...

  19. 13 A 17-year-old young man with snakebite
    (pp. 30-31)

    A 17-year-old young man was bitten on the left foot by a green-coloured snake. The snake was caught and brought to ED.

    1. What is the name of the snake?

    2. Name the features of this snake’s head.

    3. What precautions do you need to take when examining the snake even after it has been killed?

    4. If in doubt, how do you identify a snake?

    5. What are two antivenoms available for the above snakebite?

    1. It is a bamboo snake or white-lipped pit viper (Trimeresurus albolabris). It represents the commonest snakebite in Hong Kong.

    2. The snake has...

  20. 14 A 16-year-old girl with severe vaginal bleeding
    (pp. 32-34)

    A 16-year-old girl presented to ED because of severe vaginal bleeding for two hours. She was afebrile and had no abdominal pain. Abdominal examination revealed a pelvic mass up to the umbilicus. A urine pregnancy test was positive. Abdominal USG was performed.

    1. What are the USG findings?

    2. What is the clinical diagnosis?

    3. What additional symptoms or signs may occur?

    4. What should be the most important investigation?

    5. What should be the definitive treatment?

    6. If the patient also complains of haemoptysis, what diagnosis should be considered?

    1. USG reveals a uterus enlargement, and the uterus is...

  21. 15 A 16-year-old boy with left eye injury
    (pp. 35-37)

    A 16-year-old boy presented to ED because his left eye had been hit by another player’s elbow during a basketball game. An X-ray of the face was taken.

    1. What is the name of this X-ray view?

    2. What is the X-ray finding?

    3. What is the diagnosis?

    4. What are two theories on the mechanism of the above diagnosis?

    5. What physical examinations should be done?

    1. This is the occipitomental (Waters) view, which is useful to evaluate most midface fractures.

    2. There is left orbital emphysema (intraorbital air) or black eyebrow sign, which is diagnostic of a fracture...

  22. 16 A 65-year-old man with severe chest pain
    (pp. 38-39)

    A 65-year-old man with a history of diabetes mellitus and MI occurring 14 years ago presented to ED with severe chest pain. An ECG was performed.

    1. What is the ECG diagnosis?

    2. What should be the immediate treatment?

    3. What are five manoeuvres to increase the efficacy of the above treatment?

    4. What is the most useful medication for the above condition that is refractory to the above treatment?

    1. The ECG first shows sinus tachycardia, then VT and, finally, degeneration to VF.

    2. The immediate treatment is defibrillation (monophasic 360J or equivalent biphasic).

    3. The efficacy of defibrillation...

  23. 17 A 23-year-old man with neck injury
    (pp. 40-41)

    A 23-year-old man with a neck injury presented to ED. A lateral cervical spine X-ray was taken.

    1. What is the X-ray finding?

    2. How is the above injury classified? Which type is unstable?

    3. What other X-ray views could identify the above injury?

    4. What additional information can a CT scan of the cervical spine give?

    1. There is a displaced odontoid fracture of C2/dens fracture.

    2. An odontoid fracture of C2 is classified as type I, II and III. Type I is a fracture of the tip of the dens. Type II is a fracture at the base...

  24. 18 A 43-year-old man with painful facial rash
    (pp. 42-43)

    A 43-year-old man presented to ED with a painful facial rash.

    1. What is the clinical diagnosis?

    2. What is the involved nerve?

    3. What is the potential ocular complication?

    4. Is the above ocular complication likely in this patient?

    5. What are the ED treatments?

    6. Are steroid eye drops indicated if there is ocular involvement?

    1. The clinical diagnosis is herpes zoster ophthalmicus.

    2. The ophthalmic division of the trigeminal nerve is involved.

    3. The potential ocular complication is herpes zoster keratitis. A slit lamp examination should look for punctate epithelial keratitis and pseudodendrites in the cornea.

    4....

  25. 19 An 18-year-old young man with chest pain
    (pp. 44-46)

    An 18-year-old young man presented to ED because of having sudden onset of chest pain for one day. His BP was 120/65 mmHg and his pulse was 75/min. The pain increased with deep inspiration. He had no fever, chills or rigor. An ECG revealed sinus rhythm and no ischaemic changes. A CXR was taken.

    1. What are the X-ray findings?

    2. What is the diagnosis?

    3. What signs might be present on physical examination?

    4. What are the other radiological signs in the above diagnosis?

    5. What questions should be asked when taking the history?

    6. What should be the...

  26. 20 A 48-year-old man with severe chest pain
    (pp. 47-49)

    A 48-year-old man presented to ED because of having severe chest pain for two hours. His BP was 100/60 mmHg and pulse was 130/min. An ECG revealed sinus tachycardia, and there were no ischaemic changes. A CXR was taken.

    1. What are potential life-threatening differential diagnoses for chest pain?

    2. What are the X-ray findings?

    3. What is the most likely diagnosis?

    4. What should be the next investigation?

    5. What should be the treatment?

    1. The life-threatening differential diagnoses for chest pain include the following:

    MI/unstable angina

    pulmonary embolism

    tension pneumothorax

    aortic dissection

    oesophageal rupture

    2. The CXR shows...

  27. 21 A teenage girl with rash over the lower limbs
    (pp. 50-51)

    A teenage girl presented to ED because of a palpable pupuric rash over the lower limbs that been there for two days. She was afebrile.

    1. What is the diagnosis?

    2. Can patients with the above diagnosis present with seizures?

    3. What other symptoms may be present?

    4. What are the differential diagnoses of purpuric rash in children?

    1. The diagnosis is Henoch-Schönlein purpura. It also is called anaphylactoid purpura.

    2. Yes, Henoch-Schönlein purpura is a systemic vasculitis. Patients can present with seizures as a first symptom because of involvement of the cerebral vessels. Other CNS presentations include coma and...

  28. 22 An 80-year-old man with right lower quadrant pain
    (pp. 52-53)

    An 80-year-old man presented to ED with right lower quadrant pain. He had pallor and sweating. His BP was 84/51 mmHg and pulse was 104/min. An emergency bedside USG was performed.

    1. What are the USG findings?

    2. What is the clinical diagnosis?

    3. If there is no free intraperitoneal fluid in the USG findings, is a CT abdomen indicated to delineate whether there is rupture or not?

    4. What is the ED treatment?

    1. There is a 6-cm x 8-cm abdominal aorta aneurysm with a large thrombus over the right lower quadrant.

    2. Because the patient is in shock,...

  29. 23 A 20-year-old man with palpitations
    (pp. 54-56)

    A 20-year-old man presented to ED because of having palpitations for one hour. His BP was 90/55 mmHg and pulse was 198/min. He was conscious and there was no respiratory distress. An ECG was performed.

    1. What are the ECG findings?

    2. What is the diagnosis?

    3. What is the drug of choice to terminate this arrhythmia?

    4. What is the definitive treatment?

    1. The ECG shows wide-complex tachycardia (QRS 138 ms), RBBB pattern and superior axis deviation.

    2. The diagnosis is fascicular VT.

    3. Verapamil 5 mg slow IV is the drug of choice to terminate this arrhythmia. Adenosine...

  30. 24 A 6-year-old girl with diarrhoea
    (pp. 57-59)

    A 6-year-old girl was referred to ED from an out-patient clinic for suspected cholera. She had diarrhoea a week earlier, and a stool specimen for culture was saved. She was called back to ED after the stool result was available. Her diarrhoea had already subsided. She was clinically not dehydrated.

    1. Is this a notifiable disease? Is it a quarantinable disease?

    2. Should you give antibiotics for her condition?

    3. What are four quarantinable infectious diseases in Hong Kong?

    1. Both answers are no. V. cholerae species comprises a host of organisms classified on the basis of the carbohydrate determinants...

  31. 25 An 18-year-old young woman with neck injury
    (pp. 60-61)

    An 18-year-old young woman suffered from a road traffic accident. She was in respiratory arrest on arrival to ED. She immediately was intubated and mechanically ventilated. A lateral cervical spine X-ray was taken.

    1. What are the X-ray findings?

    2. What are the signs of spinal cord injury in an unconscious patient (not restricted to the above case)?

    3. How should the above patient have been intubated when she arrived in ED?

    1. The lateral cervical spine X-ray reveals atlantoaxial dissociation. The C1 ring is displaced anteriorly to C2. There is also a marked prevertebral soft tissue swelling over the...

  32. 26 A 15-year-old girl with right elbow injury
    (pp. 62-64)

    A 15-year-old girl injuried her right elbow after falling from a bicycle and presented to ED. An X-ray of the elbow was taken.

    1. What is the X-ray diagnosis?

    2. Is there any significant fat pad sign? Why?

    3. What are the four radiographical types for this diagnosis?

    4. What is the treatment?

    5. What is the order of each ossification centre of the elbow?

    What is its importance in assessing elbow injuries in children?

    1. The X-ray shows an inferiorly displaced fracture of the medial epicondyle.

    2. There is a normal looking anterior fat pad and no posterior fat...

  33. 27 A 44-year-old man with head injury
    (pp. 65-67)

    A 44-year-old man was brought to ED because of a head injury caused by a metal spring. He had lost consciousness transiently and recovered spontaneously. There was no amnesia. Skull X-rays were taken.

    1. What are the X-ray findings?

    2. What is likely to present on examination of the wound?

    3. What are the potential complications?

    4. What analgesic is contraindicated for the above condition? Why?

    1. There is intracranial air/pneumocephalus in the frontal region on the lateral view. There is air inside the left orbit (or orbital emphysema) in the AP view.

    2. Subcutaneous emphysema around the eye and...

  34. 28 A 39-year-old woman with increasing swelling of face
    (pp. 68-69)

    A 39-year-old woman presented to ED with increasing swelling of the face that she had experienced for one week. There were distended neck veins. A CXR was taken.

    1. What are the X-ray findings?

    2. What is the diagnosis?

    3. What are the likely causes?

    4. What is the treatment?

    1. The X-ray shows widened upper mediastinum and elevation of the right hemidiaphragm.

    2. The diagnosis is superior vena cava syndrome.

    3. Causes might be CA lung, lymphoma or malignant thymoma.

    4. There should be an urgent oncology referral and the underlying malignancy be managed with radiotherapy or chemotherapy.

    Obstruction...

  35. 29 A 5-year-old boy with left facial pain
    (pp. 70-71)

    A 5-year-old boy presented to ED complaining of left facial pain that he had experienced for one day.

    1. What is the X-ray finding?

    2. What is the nature of the above finding?

    3. What symptoms would you expect the patient to have?

    4. What is the ED treatment?

    5. What are the potential complications?

    1. There is a round, radiopaque foreign body in the left nasal cavity.

    2. The radiographical appearance of the foreign body has the distinctive double contour that is characteristic of button battery (the classic halo sign). It may contain zinc, mercury, silver, nickel, lithium, potassium...

  36. 30 A 42-year-old pregnant woman with repeated vomiting and dehydration
    (pp. 72-73)

    A 42-year-old woman presented to ED with repeated vomiting and dehydration. She was eight weeks pregnant. There was no vaginal bleeding. A transvaginal USG was performed.

    1. What are the USG findings?

    2. What is the clinical diagnosis?

    3. Why is an early USG important for the above diagnosis?

    4. What is the cause of the repeated vomiting?

    5. What other important diagnoses should be considered for repeated vomiting?

    6. What are USG findings of intrauterine pregnancy?

    1. There are two intrauterine gestational sacs. Fetal parts are visible in each sac.

    2. The clinical diagnosis is twin pregnancy complicated by...

  37. 31 A 50-year-old man with severe chest pain
    (pp. 74-75)

    A 50-year-old man presented to ED with severe chest pain that he had been experiencing for 45 minutes. A CXR was normal. A troponin T was 0.02 ng/mL (normal < 0.04 ng/mL). His chest pain decreased after arrival to ED. An ECG was performed.

    1. What are the ECG findings?

    2. What is the most important differential diagnosis that can be life threatening?

    3. What is the anatomical site of the lesion?

    1. The ECG reveals normal axis and sinus rhythm of 87/min. There are biphasic T-wave inversions over the V2–V4. There is also a T-wave inversion over the...

  38. 32 A 60-year-old woman with abdominal pain and vomiting
    (pp. 76-77)

    A 60-year-old woman, complaining of acute onset abdominal pain and vomiting for one day, presented to ED. A supine AXR was taken.

    1. What are the AXR findings?

    2. What is the diagnosis?

    3. What are the ED treatments?

    4. What is the most important physical examination that needs to be done?

    1. The AXR shows multiple dilated small bowel and an absence of large bowel gas. The small bowel occupies a central position in the abdomen. It is characterized by numerous mucosal folds called valvulae conniventes (or plicae circulares) that circumferentially indent the intestinal wall and cross the entire...

  39. 33 A 5-year-old boy with high fever
    (pp. 78-80)

    A 5-year-old boy presented to ED because of having a high fever for four days and a generalized rash over the whole body for one day.

    1. What signs are present?

    2. What is the most likely diagnosis?

    3. What other physical findings are likely to be present?

    4. What is the most significant complication of the above diagnosis?

    5. What are the treatments?

    1. Signs are the following:

    strawberry tongue

    left cervical lymphadenopathy

    erythematous, polymorphous rash over the trunk

    2. The most likely diagnosis is Kawasaki disease (mucocutaneous lymph node syndrome).

    3. Other positive physical findings include peripheral extremity...

  40. 34 A 45-year-old motorcyclist with anterior chest wall contusion
    (pp. 81-83)

    A 45-year-old motorcyclist presented to ED after a motor vehicle accident. There were contusion marks over the anterior chest wall. A CXR was taken.

    1. What are the X-ray findings?

    2. What is the likely diagnosis?

    3. What are other possible X-ray features of the above diagnosis?

    4. What should be the next investigation for the above diagnosis?

    1. The X-ray findings show a widened mediastinum (> 8 cm in this supine film) and a widened left paraspinal stripe, extending above the aortic knob towards the apex of the lung and forming the left pleural cap. There is also a...

  41. 35 A 68-year-old woman with drooling of saliva and left ear pain
    (pp. 84-86)

    A 68-year-old woman presented to ED with drooling of saliva and left ear pain that she had experienced for two days.

    1. What are the findings in the clinical photograph?

    2. What other possible symptoms may the patient present?

    3. What are the possible causes of the above findings?

    4. What is the ED treatment?

    1. The patient has left lower motor neurone facial nerve palsy involving the entire left face. There is no forehead sparing. Emergency physicians need to differentiate between an upper and lower motor neurone lesion of the facial nerve. A lower motor neurone lesion occurs with...

  42. 36 A 50-year-old man with confusion
    (pp. 87-89)

    A 50-year-old man presented to ED because of confusion. He was afebrile, and no skin rash was detected. A CT scan of brain was normal. An LP was performed. An antibiotic was started after the LP. The following report was urgently phoned by the laboratory.

    1. What is the diagnosis? What is the likely causative organism?

    2. What antibiotics should be started initially?

    3. What should be done for infection control?

    4. Who needs antibiotic prophylaxis?

    5. Is a vaccine available for the above serotype organism?

    1. The diagnosis is bacterial meningitis. N. meningitidis type B is likely the causative...

  43. 37 A 37-year-old woman with per vaginal bleeding and lower abdominal pain
    (pp. 90-91)

    A 37-year-old woman presented to ED with per vaginal bleeding and lower abdominal pain that she had experienced for one day. Her BP was 153/89 mmHg and pulse was 90/min. She was afebrile. A bedside haemoglobin was 7.8 g/dL. A bedside transabdominal USG was performed.

    1. What are the USG findings?

    2. What is the diagnosis?

    3. What is a heterotopic pregnancy?

    4. What is a pseudosac?

    1. There is free intraperitoneal fluid in Morrison’s pouch, a complex left adnexal mass and a suspected small pseudosac within the uterine cavity.

    2. The diagnosis is ruptured left ectopic pregnancy.

    3. Heterotopic...

  44. 38 A 29-year-old man with palpitations
    (pp. 92-93)

    A 29-year-old man presented to ED because of having palpitations for two hours. His BP was 100/71 mmHg. An ECG was performed.

    1. What are the ECG findings?

    2. What is the clinical diagnosis?

    3. What is the drug of choice?

    4. What are common exacerbating factors of this arrhythmia?

    1. The ECG findings are the following:

    wide complex tachycardia of 185/min (QRS interval 146 ms)

    LBBB morphology

    right inferior axis deviation

    2. The diagnosis is RVOT VT.

    3. IV adenosine is the drug of choice. Verapamil and vagal manoeuvres may also produce effective termination of the tachycardia.

    4. The...

  45. 39 A 39-year-old woman who attempted suicide by hanging
    (pp. 94-95)

    A 39-year-old woman attempted suicide by hanging. She was rescued immediately by her son and brought to ED. There was a mild ligature mark over the neck and spontaneous full-range movement of the neck. She was not in respiratory distress. Other physical examinations were normal. A lateral neck X-ray was taken.

    1. What are the X-ray findings?

    2. What symptoms might the patient have?

    3. What are the differential diagnoses?

    4. What should be the next investigations?

    1. There is surgical emphysema over the lateral neck X-ray along the prevertebral tissue of the whole cervical spine. There is no bony...

  46. 40 A 50-year-old woman with insomnia and headache
    (pp. 96-97)

    A 50-year-old woman presented to ED with insomnia and headache that she had been experiencing for one week. A psychiatrist was consulted, and the presumptive diagnosis was depression. A plain CT brain scan was performed.

    1. What are the CT findings?

    2. What is the suspected clinical diagnosis?

    3. Her renal function was: Na 129; K 3.6; Ur 2.0; Cr 61. What could be the cause of hyponatraemia?

    4. What are three likely visual disturbances?

    5. What should be the definitive treatment? What kind of assessment should be done before that?

    1. There is round hyperdensity in the sellar region...

  47. 41 A 45-year-old motorcyclist with left foot injury
    (pp. 98-99)

    A 45-year-old motorcyclist crushed his left foot during a motor vehicle crash and presented to ED. An X-ray of his left foot was taken.

    1. What are the X-ray findings?

    2. What is the clinical diagnosis?

    3. What are two types of displacement for the above diagnosis?

    4. What early complications should be anticipated?

    5. What is the ED treatment?

    1. There is widening space between the first and second metatarsal in the AP view. The medial margin of the base of the second metatarsal does not align with the medial margin of the intermediate cuneiform on the AP view....

  48. 42 A 9-day-old neonate with left eye discharge
    (pp. 100-101)

    A 9-day-old neonate presented to ED with left eye discharge and crusting that had been there for one day.

    1. What is the diagnosis?

    2. What are the common etiological agents?

    3. What organism causes the most serious complications? What are the complications?

    4. What is the treatment for the above organism?

    5. If there is presence of blood-stained discharge, what is the most likely causative organism? What should be the treatment?

    1. The diagnosis is ophthalmia neonatorum or neonatal conjunctivitis.

    2. The common etiological agents include the following:

    Staphylococcus aureus

    Chlamydia trachomatis

    Neisseria gonorrhoeae

    herpes simplex virus

    3. N....

  49. 43 A 16-year-old boy with retrosternal chest pain and dizziness
    (pp. 102-103)

    A 16-year-old boy presented to ED because of having retrosternal chest pain for three days. He also complained of repeated vomiting and dizziness. His BP was 90/58 mmHg and pulse was 100/min. Electrolytes were normal. An ECG was performed.

    1. What are the ECG findings?

    2. What is the clinical diagnosis?

    3. What is the most common ECG abnormality in the above diagnosis?

    4. What is the gold standard for diagnosis?

    1. The ECG shows accelerated idioventricular rhythm and atrio-ventricular dissociation. QRS complexes are widened. There are ST elevations over V1 and V2 leads.

    2. The clinical diagnosis is acute...

  50. 44 A 38-year-old man with head injury
    (pp. 104-105)

    A 38-year-old man, suffering from a head injury by a metal bar, presented to ED. He had experienced a transient loss of consciousness. He was alert and had no neurological deficit. A CT scan of brain was performed.

    1. What are the CT scan findings?

    2. What is the clinical diagnosis?

    3. What is “swirl sign” in the above diagnosis (not present in our patient)?

    4. What is Cushing response?

    5. If the patient deteriorates rapidly and develops signs of herniation after the CT, what should be done in ED?

    1. There was a small biconvex-shaped, hyperdense haematoma over the...

  51. 45 A 13-year-old boy with right knee injury
    (pp. 106-107)

    A 13-year-old boy twisted his right knee while running and presented to ED. His knee was kept in a flexed position. X-rays of right knee were taken.

    1. What is the diagnosis?

    2. Describe other types of the above diagnosis?

    3. How should the above condition be treated in ED?

    4. What X-ray views are useful after the above treatment?

    1. The diagnosis is lateral patellar dislocation.

    2. The patella may dislocate in numerous directions. Lateral dislocations are the most common type. The patella may dislocate superiorly, medially, horizontally and intraarticularly in rare instances.

    3. Closed reduction of lateral patellar...

  52. 46 A 52-year-old man with numbness and spasm of four extremities
    (pp. 108-109)

    A 52-year-old man presented to ED because of numbness and spasm of his four extremities after taking some herbal medication. His BP was 105/77 mmHg and pulse was 103/min. An ECG was performed.

    1. What are the ECG findings?

    2. What is the diagnosis?

    3. What are three suspected Chinese herbal medications? What are their uses in Chinese medicine?

    4. What are their main toxicities on humans?

    5. What other herbs can cause similar presentations?

    6. What are the ED treatments?

    7. What is the first-line anti-arrhythmic drug for VT induced by such poisoning?

    1. The ECG shows sinus rhythm...

  53. 47 An elderly woman with inability to close the mouth
    (pp. 110-111)

    An elderly woman presented to ED unable to close her mouth. There was no history of trauma.

    1. What is the clinical diagnosis?

    2. What is the ED treatment?

    3. What should be the follow-up care?

    1. The clinical diagnosis is bilateral temporal mandibular joint dislocation or jaw dislocation. Dislocation usually results from a vigorous yawn or excessive opening of the mouth during laughing, eating or dental extraction. It may be due to direct trauma to the chin while the mouth is open. Anterior dislocation is the most common and usually is bilateral. Unilateral dislocation will result in deviation of...

  54. 48 A 41-year-old woman with right hip injury
    (pp. 112-114)

    A 41-year-old woman presented to ED with right hip pain after being hit by a trolley. An X-ray of pelvis was taken.

    1. What is the X-ray diagnosis?

    2. Describe the leg position of a patient with the above condition?

    3. How to should the above condition be treated in the ED?

    4. What additional X-ray views are indicated after the above treatment?

    5. What additional information can be obtained from a CT scan?

    6. What is the immediate complication of the above condition?

    1. The X-ray diagnosis is right posterior hip dislocation.

    2. The leg will appear shortened and...

  55. 49 A 55-year-old man with fever and cough
    (pp. 115-117)

    A 55-year-old man presented to ED because of having a productive cough, fever and mild SOB for one day. A CXR revealed right middle lobe consolidation. Chest infection was diagnosed and oral amoxicillin/clavulanate (1g twice daily) was prescribed. Sputum was sent for culture.

    1. Can azithromycin be used to treat the above isolate?

    2. What are two other common bacteria that cause CAP?

    3. What is the most appropriate oral antibiotic for the patient after receiving the sputum culture results?

    4. What are the indications of respiratory fluoroquinolones in CAP?

    1. No, the above isolate of S. pneumoniae is resistant...

  56. 50 A 62-year-old woman with dizziness and severe headache
    (pp. 118-119)

    A 62-year-old woman complainings of dizziness and severe headache presented to ED. She was unconscious on arrival. Her BP was 244/127 mmHg and pulse was 62/min. A GCS was E1V2M4. An urgent CT scan of brain was performed.

    1. What are the CT scan findings?

    2. What is the clinical diagnosis?

    3. What is the most likely cause of the above condition? Where are common sites?

    4. What is name of the grading system for the above condition? What is the grading of this patient?

    5. What are common complications?

    1. There is blood in the sulci on the sylvian...

  57. 51 A 25-year-old man with chest pain
    (pp. 120-121)

    A 25-year-old man presented to ED because of having chest pain for two days and which had increased in severity two hours before his arrival to ED. An ECG was performed.

    1. What are the ECG findings?

    2. What is the clinical diagnosis?

    3. What ECG evidence supports your diagnosis?

    4. What is the mainstay of treatment for the idiopathic cause of the above condition?

    5. Initial blood investigations revealed: increased Troponin T 1.44 ng/mL (normal < 0.04), CK 631, LDH 437; CBP and LRFT were otherwise normal. Would you change the diagnosis?

    6. What further bedside investigations are indicated...

  58. 52 A 48-year-old man with facial injury
    (pp. 122-124)

    A 48-year-old man presented to ED after his face had been hit by a container half an hour earlier. There was profuse bleeding from the nose and mouth as well as severe facial swelling. A CT of the facial bones was performed.

    1. Name one immediate danger for the patient.

    2. How should the above danger be handled?

    3. What is the name of the classification system for midface fractures?

    4. How should massive bleeding be controlled ?

    1. The patient’s airway is in immediate danger. The airway potentially is compromised because of the severe facial or oropharyngeal swelling resulting...

  59. 53 A 60-year-old man with dizziness and weakness
    (pp. 125-127)

    A 60-year-old man presented to ED with complaints of dizziness and weakness that he had experienced for one day. An ECG was performed.

    1. What are the ECG findings?

    2. What is the diagnosis?

    3. What are the ED treatments?

    1. The ECG findings included the following:

    small P wave

    widened QRS (200 ms)

    peaked T wave in leads II, III, V3, V6 (tall, narrow based)

    2. The diagnosis is hyperkalaemia. An urgent serum potassium test revealed K = 6.6 mmol/L (normal 3.5–5.1 mmol/L)

    3. The ED treatments include the following:

    obtain an IV access and connect to cardiac...

  60. 54 An 11-year-old girl with left knee injury
    (pp. 128-129)

    An 11-year-old girl fell down and injured her left knee during a hurdles race. She was unable to move her left leg immediately after the injury. She presented to ED and an X-ray of the left knee was taken.

    1. What are the X-ray and clinical findings?

    2. What important mechanism needs to be checked during the physical examination?

    3. What are the components of the above mechanism?

    4. What should be the treatment?

    5. What is Osgood-Schlatter’s disease?

    1. There are abrasions over the left knee region, a grossly swollen left knee joint and swelling over the left upper...

  61. 55 A 75-year-old man with fever, hoarseness and difficulty in swallowing
    (pp. 130-131)

    A 75-year-old man presented to ED with fever, hoarseness and difficulty in swallowing that he had experienced for three days. A neck soft tissue X-ray was taken.

    1. What are the X-ray findings?

    2. What is the ED treatment?

    3. What additional investigation is useful?

    1. There is grossly swollen prevertebal soft tissue extending from C1 to C7, compatible with retropharyngeal abscess. There is gas formation inside the swelling.

    2. The emergency physician should maintain the patient’s ABC. An anaesthetist and ENT surgeon or general surgeon should be alerted and manage the patient together. The first step is to evaluate...

  62. 56 A 60-year-old diabetic man with left hand pain and swelling
    (pp. 132-133)

    A 60-year-old diabetic man presented to ED because of experiencing left hand pain and swelling for one month. There was no history of trauma. Two weeks earlier in China, he had been given a drug injection into the swelling. There was a 4 cm x 4 cm swelling over the dorsum of the hand and some weakness when the patient tried to extend his fingers. The swelling was aspirated and there were acid-alcohol-fast bacilli that were confirmed to be Mycobacterium marinum.

    1. What are important environmental factors for the above infection?

    2. What drug might he have been injected with...

  63. 57 A 19-month-old boy with drowsiness and multiple bruises
    (pp. 134-135)

    A 19-month-old boy presented to ED with drowsiness and multiple bruises over the body. A CXR was taken.

    1. What is the X-ray diagnosis?

    2. What is the most likely diagnosis?

    3. What are five types of the above diagnosis?

    4. What are five fractures that are characteristic of the above diagnosis?

    1. The CXR reveals a fractured right clavicle.

    2. The most likely diagnosis is child abuse or nonaccidental injury.

    3. Five types of child abuse include the following:

    physical abuse (bruises, fractures, wounds and burns)

    sexual abuse

    poisoning

    emotional neglect

    Munchausen’s syndrome by proxy

    4. Five fractures characteristic...

  64. 58 A 21-year-old woman with severe epigastric pain
    (pp. 136-137)

    A 21-year-old woman presented to ED because of having sudden onset severe epigastric pain for three hours. Her BP was 120/50 mmHg and pulse was 95/min. An erect CXR was taken.

    1. What is the X-ray finding?

    2. What is the diagnosis?

    3. What could be other causes for the above X-ray finding?

    4. What signs may be present in a supine AXR?

    5. What is the ED treatment?

    1. There is free gas under the right hemidiaphragm and left hemidiaphragm (less obvious).

    2. The diagnosis is perforated peptic ulcer or perforated hollow viscera.

    3. Air under the diaphragm can...

  65. 59 A 58-year-old man with dyspnoea and chest tightness
    (pp. 138-139)

    A 58-year-old man presented to ED because of having dyspnoea and chest tightness for one week. His BP was 184/100 mmHg and pulse was 120/min. Pulse oximetry was 95% on room air. An ECG was performed.

    1. What are the ECG findings?

    2. What is the most likely diagnosis?

    3. What is the most common CXR finding of the above diagnosis?

    4. What should be the next investigation to confirm the diagnosis?

    1. The ECG findings include the following:

    sinus tachycardia of 126/min

    right axis deviation

    deep S wave in lead I and T-wave inversion in Lead III

    2. The...

  66. 60 A 42-year-old woman with lower chin pain and swelling
    (pp. 140-141)

    A 42-year-old woman presented to ED because of experiencing persistent lower chin pain and swelling for five days despite being given antibiotic treatment by a general practitioner.

    1. What are the clinical findings from the photograph?

    2. What is the likely diagnosis?

    3. What is the likely origin of the infection?

    4. What are three complications of the above diagnosis?

    5. What are the treatment priorities?

    1. There is extensive erythema and swelling over the chin.

    2. Ludwig’s angina is the most likely diagnosis. Differential diagnoses include submandibular gland abscess and cervical lymphadenitis.

    3. The origin of infection is likely...

  67. 61 A 55-year-old man with left foot pain and swelling
    (pp. 142-143)

    A 55-year-old man with diabetes mellitus presented to ED because of having left foot pain, erythema and swelling for three days. Gangrenous skin was over the dorsum of the foot. There was no history of trauma. An X-ray of the foot was taken.

    1. What are the X-ray findings?

    2. What are three differential diagnoses?

    3. What are the common organisms causing the above differential diagnoses?

    4. What is the ED management?

    1. The X-ray reveals the presence of subcutaneous gas.

    2. The differential diagnoses include necrotizing cellulitis, necrotizing fasciitis and gas gangrene.

    3. For diabetic patients, mixed Gram-negative bacilli...

  68. 62 A 19-year-old young man with right arm injury
    (pp. 144-146)

    A 19-year-old young man injured his right arm while playing basketball and presented to ED.

    1. What clinical findings are shown in the photograph?

    2. What is the clinical diagnosis?

    3. What is the “badge” area?

    4. What is the ED treatment?

    5. What bony lesions are associated with recurrent shoulder dislocation?

    1. The patient’s right upper limb is held in slight abduction and external rotation with support from the left arm. There is a squared-off, boxlike appearance over the right shoulder. The rounded contour of the right deltoid muscle is lost.

    2. The clinical diagnosis is right anterior shoulder...

  69. 63 A 55-year-old man with right eye injury
    (pp. 147-149)

    A 55-year-old man presented to ED because of a right eye injury. There was a full thickness corneal laceration. The pupil was irregular (teardrop) in shape. An X-ray orbit was taken.

    1. What is the X-ray finding?

    2. What should be the next investigation?

    3. What is the ED treatment?

    1. The X-ray orbit shows a metallic foreign body inside the right orbit. Physical examination may reveal loss of anterior chamber depth or extrusion of the ocular contents. A marked decrease in visual acuity is expected.

    2. The next investigation should be CT orbits to evaluate the intraocular foreign body....

  70. 64 A 39-year-old woman with dyspnoea
    (pp. 150-151)

    A 39-year-old woman presented to ED because of experiencing sudden onset dyspnoea for one day. She had a history of systemic lupus erythematosus. A spiral CT thorax was performed.

    1. What are the CT findings? What is the diagnosis for her dyspnoea?

    2. What are two possible causes?

    3. What history should be taken to identify the anatomical source for her complaint? What are two helpful noninvasive imaging modalities?

    4. If she suddenly sweats, looks pale, has a BP of 85/50 mmHg and a pulse of 116/min, what ED treatment should be given?

    1. There are filling defects in the...

  71. 65 A 23-year-old man with an electric shock
    (pp. 152-153)

    A 23-year-old construction site worker, suffering from an electric shock after stepping on a broken electrical cord at work, presented to ED.

    1. What are the characteristics of the wounds?

    2. What is the likely current pathway? How could “entry” wound and “exit” wound be distinguish clinically?

    3. What underlying organs or tissues are in danger?

    4. What are the clinical parameters to guide fluid resuscitation therapy?

    1. There is a sharply demarcated charred wound, extending into the deeper tissues over the pulp of the big toe. There are two “explosive”-like wounds over the knuckles of the fingers.

    2. The...

  72. 66 A 40-year-old woman with persistent wound pain
    (pp. 154-155)

    A 40-year-old woman presented to ED because of persistent pain and redness around her left forearm that she had experienced for one week. She had a history of a pricking injury by a wooden object on her wrist one week earlier. An X-ray of that last ED attendance was normal. A bedside USG was performed at this second visit.

    1. What is the clinical diagnosis?

    2. What technique should be used in the bedside USG examination in this case?

    3. What are the USG findings?

    1. With a history of pricking injury, retained foreign body leading to persistent infection should...

  73. 67 A 30-year-old woman with right-sided abdominal pain
    (pp. 156-157)

    A 30-year-old woman presented to ED because of having right-sided abdominal pain for one day. An AXR was taken and an abdominal USG was performed.

    1. What are the AXR findings?

    2. What are the USG findings, including the echogenic shadow? What is one likely finding in this case that does not show on this single static image?

    3. What are the traditional physical signs possibly detected in her?

    4. What are the components of the arrow pointed USG shadow?

    5. If the patient recurs with the same diagnosis, what rare inadequate surgical treatment could account for this?

    1. There...

  74. 68 A 26-years-old woman with pain and swelling of left index finger
    (pp. 158-159)

    A 26-years-old woman presented to ED because of pain and swelling at the left index finger pulp. The patient was diagnosed as having an acute pulp infection. An X-ray of the left index finger was taken at her first attendance.

    An incision and drainage of pus was performed. The patient received antibiotic treatment and regular wound dressing. The patient presented again approximately ten days later. The wound pus culture grew Staphyloccocus aureus that was sensitive to cloxacillin. An X-ray at the follow-up was taken.

    1. What are the initial X-ray findings?

    2. What are the second X-ray findings?

    3. What...

  75. 69 A 40-year-old man with snake bite
    (pp. 160-161)

    A 40-year old man, who had been bitten by a snake an hour earlier, presented to ED. The snake was killed and brought to ED for identification. The snake was about two feet in length.

    1. What is the common name or species name of the snake?

    2. What toxins does the snake venom contain?

    3. What investigations should be done in ED?

    4. What is the earliest physical sign of systemic neurological involvement?

    5. What are the indications for antivenom?

    6. What precautions should be carried out in antivenom administration?

    7. What are the complications of antivenom?

    1. The...

  76. 70 A 65-year-old man with palpitations
    (pp. 162-163)

    A 65-year-old man presented to ED because of palpitation for two hours. Blood pressure was 120/80 mmHg and pulse was 169/min. He was conscious and there was no respiratory distress. An ECG was performed.

    1. What is the ECG diagnosis?

    2. What are the four medications that you need to avoid?

    3. What are the medications that you can use?

    4. If the patient becomes more breathless and blood pressure is 80/50 mmHg, what is the treatment?

    1. ECG findings include the following: Irregular wide complex tachycardia of 169 per min and no P wave is identified. There are upright...

  77. Index
    (pp. 164-165)