Emergency Medicine Casebook

Emergency Medicine Casebook

Leung Ling Pong
Copyright Date: 2004
Pages: 156
  • Cite this Item
  • Book Info
    Emergency Medicine Casebook
    Book Description:

    Emergency medicine is a new and rapidly developing specialty. The fast patient flow, the large patient load, and the diversified clinical presentation make the emergency department a challenging place to work in. For the same reasons, the practice of emergency medicine is full of pitfalls. A mistake can be fatal. The 72 case histories included in this book cover a wide range of subjects and are real-life problems that may be encountered in emergency departments. Presented in the form of a clinical quiz, each case history is followed by questions. Discussion of the answers, with references, is given at the end of each quiz. Written for doctors working in the emergency department, the book serves as a stimulus for further self-study and an aid for professional examinations. Medical students, nurses and paramedics may also find it useful.

    eISBN: 978-988-220-120-0
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Table of Contents
    (pp. iii-vi)
  3. Preface
    (pp. vii-1)
  4. 1 Body packing
    (pp. 2-3)

    Early one morning, the police brought a man to A&E. They suspected him of being an international drug smuggler and to have swallowed a few packets of ‘white powder’ prior to attempting to go overseas from the airport. The police requested that you gave him something to drink to make him vomit so that they could recover the swallowed drugs.

    Q1 Should you give this man an emetic?

    Q2 What complications would you expect in this case?

    Q3 How would you manage this case?

    1. The use of emetics in this situation is not recommended. It is unwise to give an...

  5. 2 A not-to-miss cause of epistaxis
    (pp. 4-5)

    A 50-year-old man came to A&E complaining of epistaxis, although the bleeding had already stopped before he was seen. This was his second attendance for the same problem. He said that he had been healthy until about three months earlier. He had then developed an intermittent thick nasal discharge. He was treated in the outpatient clinic of a private hospital as sinusitis. After some initial improvement, the symptoms recurred and became worse. He had come to A & E the day before and had been prescribed antibiotics, which he did not think would help. Examination of the anterior nasal space revealed...

  6. 3 Drug overdose
    (pp. 6-7)

    A young woman was rushed into A&E by the ambulance crew. She was reported to have been found in a state of confusion in her home. The only information available was from her landlady. She said that the woman had had a fierce quarrel with her boyfriend some hours earlier. Physical examination showed the patient to be semi-conscious and febrile. Her blood pressure was 80/60 mmHg and the pulse rate 120/min. The pupils were dilated and reactive to light. Her skin was red and dry. The bladder was palpable.

    The emergency physician suspected that this patient had attempted suicide by...

  7. 4 Penetrating chest injury
    (pp. 8-9)

    One Christmas Eve some years ago, the A&E department received a young man who had been injured in a street fight. He had been stabbed in the left chest. The knife-handle protruded from his left anterior chest wall. The man was fully conscious, in pain and shouting. He was sweating and was tachypnoeic with a respiratory rate of 34. The blood pressure was 80/60 mmHg and the pulse rate 130/min.

    The A&E medical officer was very familiar with the ATLS protocol. He proceeded confidently with the primary survey and corrected the life-threatening complication arising from the injury.

    Q1 What is...

  8. 5 Hypothermia
    (pp. 10-11)

    A man of unknown identity was found floating in the sea. When he was brought ashore, he was semi-conscious with spontaneous breathing. On arrival at A&E, he remained drowsy. His respiratory rate was 15/min. The chest was clear. Blood pressure and pulse were normal. The A&E medical officer wanted to check his temperature.

    Q1 Do you know how it is measured?

    The man’s body temperature was 34°C.

    Q2 What re-warming methods do you know?

    After resuscitation in A&E, the man’s condition remained stable and he was transferred to the medical team for further treatment.

    Q3 What complications do you anticipate...

  9. 6 Stridor in a child
    (pp. 12-13)

    In the middle of the night, the A&E medical officer on the graveyard shift had to quickly finish his meal to go and see a three-year-old boy. The boy’s mother complained that the child was breathless. The child had had a fever since the previous afternoon and his temperature seemed to be rising despite medication from a GP. He had refused dinner and become very irritable. What worried his mother most was that he had become progressively breathless and that his breathing was noisy.

    The A&E medical officer notice that the child had a stridor and that he was also...

  10. 7 A patient with myocardial infarction and a pacemaker
    (pp. 14-15)

    An 80-year-old lady was admitted because of dizziness and nausea. She had a past history of hypertension and a pacemaker had been implanted for sick sinus syndrome. Her ECG is as below.

    Q1 How do you interpret the ECG?

    1. It shows a ventricular paced rhythm. Every QRS complex is captured by the pacemaker. There is marked ST elevation over the inferior leads.

    The ECG diagnosis is acute inferior myocardial infarction. It is confirmed by cardiac enzyme measurement.

    It is difficult to make a diagnosis of acute myocardial infarction in patients with a pacemaker. The usual ECG pattern is distorted by...

  11. 8 Opioid withdrawal
    (pp. 16-17)

    A&E had been especially busy one morning with casualties from a traffic accident. At the most inconvenient moment, the police arrived with a drug addict. As expected, the addict asked for methadone. As usual, the A&E medical officer asked him a few questions and then put a chop on the prescription sheet and referred him to the methadone clinic. The doctor also gave paracetamol as the patient had a low-grade fever. To the medical officer’s surprise, the addict reappeared two days later. This time, however, instead of walking in on his own, he was rushed in in a state of convulsion...

  12. 9 Neonatal resuscitation
    (pp. 18-19)

    Two years ago, the A&E medical officer on duty had to deal with an emergency delivery in the resuscitation room. The mother was an illegal immigrant and had had no antenatal care. The gestation was not known and the baby’s head was visible. The doctor knew he had to be decisive, so he bravely took on the role of obstetrician and conducted the delivery. Fortunately the delivery was uncomplicated and quick, but where was the paediatrician?

    The delivered baby was obviously premature. It was blue and floppy, and was gasping.

    Q1 At this stage, how do you record your findings...

  13. 10 Head injury
    (pp. 20-21)

    A 20-year-old footballer was brought to A&E by his teammates. They said that the player had sustained a head injury in a fall. He had not lost consciousness at the time of the injury. However, he became nauseous at the end of the game and vomited several times. On the way to hospital, he became drowsy and had a transient clonic convulsion.

    When the emergency physician examined him, he could find no superficial scalp wound. The patient was semi-conscious and had confused speech, but he would open his eyes to command. There was no spontaneous limb movement, but he could...

  14. 11 The elderly patient
    (pp. 22-23)

    This is a real story that happened in an A&E department in the New Territories. An elderly man presented to A&E five or six times with the same complaint of dizziness and non-specific headache. Examination was unremarkable. Preliminary blood tests and radiological studies were normal. He was referred to the psychiatrist with the provisional diagnosis of anxiety neurosis. The psychiatrist did an EEG and found a focal abnormal discharge. A CT scan later revealed a subdural haematoma.

    This is in fact not a quiz. The case is presented to remind us that extra care is needed in dealing with elderly...

  15. 12 Cardiac tamponade
    (pp. 24-25)

    A 30-year-old woman presented to A&E complaining of dyspnoea. She had been in previous good health and was not taking any regular medication. Her history of dyspnoea went back about a month when she first noticed that her exercise tolerance was decreasing. She became breathless on climbing two or three flights of stairs. Her condition progressed rapidly within a few days. When the emergency physician saw her, she was breathless at rest.

    On examination, she had bilateral ankle oedema, ascites and a pleural effusion. The liver was enlarged. Her blood pressure was low with a tachycardia of 120/min. JVP was...

  16. 13 Asthma in pregnancy
    (pp. 26-27)

    Knowledge of management of an asthmatic attack is the bread and butter of A&E practice. Some time ago, a young woman presented to A&E with an acute asthmatic attack. She was 30-weeks pregnant. Her asthma had previously been well controlled. On the day of presentation, she had developed marked wheezing after taking some herbal tea which was said to be good in pregnancy.

    Q1 What are the differential diagnoses for her wheezing?

    She was managed as a patient with acute asthmatic attack.

    Q2 Would pregnancy affect your plan of management?

    1. Differential diagnoses include:

    (a) Acute asthmatic attack.

    (b) Anaphylaxis.


  17. 14 An amputated finger
    (pp. 28-29)

    Patients with all sorts of wounds are common in the practice of A&E. Industrial accidents are particularly common. There was a patient who came to A&E with a left ring-finger injury. The finger had been caught in an electric saw. When the A&E medical officer examined the patient, he found that the finger had been amputated at the level of the mid-proximal phalanx. The wound was covered with oil and dirt. The amputated distal part of the finger was in a plastic bag.

    The patient was very anxious and kept asking the doctor if his finger could be reattached.


  18. 15 Neuroleptic malignant syndrome
    (pp. 30-31)

    A 30-year-old woman was brought to A&E by her sister, who said that the patient had increasing tremor and rigidity of the arms. The history disclosed that the patient had been a schizophrenic for more than five years and was on regular trifluoperazine and trihexyphenidyl (Artane). She had received a depot injection of fluphenazine two days before at the psychiatric outpatient clinic.

    On examination, the patient was without affect and mute. There was rigidity of all the limbs. She had a temperature of 37.8°C and her blood pressure was 110/60 mmHg with a pulse of 90/min. Examination of the other...

  19. 16 Hypoglycaemia
    (pp. 32-33)

    An elderly patient with a long history of diabetes mellitus, hypertension and ischaemic heart disease was admitted to A&E in a coma. According to his relatives, there had been no change to the patient’s drugs and his multiple medical conditions seemed to be under satisfactory control. However, for the past week the patient had grumbled that he was having frequent nightmares. On the day of admission, the patient’s relatives could not rouse him and had therefore sent for the ambulance.

    On examination, the patient was comatose and the left limbs were spastic with hyper-reflexia and ipsilateral extensor plantar response. The...

  20. 17 Gas inhalation
    (pp. 34-35)

    Inhalation of toxic gases has aroused a lot of concern recently after the death a university research assistant. People may come to A&E to seek medical treatment whenever they have or they think they have inhaled a potentially toxic gas. Some days ago, a young mother brought her baby and the home-helper to the department complaining that they had been exposed to ammonia. The vapour had been produced when a bottle containing a household cleaning agent had toppled over. The exposure was short and the irritation had caused them a mild cough.

    Q1 How would you assess these patients?


  21. 18 Hyperventilation syndrome
    (pp. 36-37)

    It was unusually peaceful at 2 am in the A&E department when the ambulance crew brought in a middle-aged woman. She complained of difficulty in breathing. Her son said that the patient had quarrelled with his father earlier. The patient’s past health was good except for some mild ‘rheumatic’ pain. She was not a smoker and had no history of lung disease.

    The A&E medical officer found that the woman was tachypnoeic with a respiratory rate of 28/min. Air entry was good without any added sound. She was alert, afebrile and pink. There was no calf swelling. The haemodynamic status...

  22. 19 The seat-belt sign
    (pp. 38-39)

    This was a traffic accident victim. A young man, a rear-seat passenger of a private car, was injured in a frontal impact collision with a truck. On arrival at A&E, he was alert with no obvious immediate life-threatening conditions on primary survey. On secondary survey, the only remarkable signs were mild periumbilical tenderness and a transverse band of bruising across the lower abdomen.

    Q1 What is this sign?

    The A&E medical officer, in view of the abdominal tenderness, ordered an abdominal X-ray.

    Q2 What do you expect to see?

    This young man was admitted to the observation room. Four hours...

  23. 20 A deadly complication of acne
    (pp. 40-41)

    Not only are girls concerned about their appearance but also boys. An adolescent boy came to A&E three years ago complaining of severe facial acne. The A&E medical officer examined him and found extensive acne on his face with some pustules around the nose. The patient was prescribed benzoyl peroxide and referred to the dermatology clinic for follow-up. However, he returned three days later with worsening of symptoms. In addition, he also had left periorbital swelling and diplopia.

    Q1 What complication had developed in this patient?

    Q2 What warning should the patient have been given in the first consultation?


  24. 21 A case of arson
    (pp. 42-43)

    The A&E department is asked to prepare for the reception of a number of arson victims. The incident has occurred in a public housing estate. Firemen report that a man had started a fire at the door of a flat. Several persons had been trapped inside the flat for about 15 minutes before being rescued. Initially, the number of casualties is not known and you are asked to go to the scene to stand by.

    Soon after your arrival, the firemen bring you the first victim. He is a middle-aged man and completely covered in soot. He is extremely frightened...

  25. 22 Smoke inhalation
    (pp. 44-45)

    A&E receives its first victim from the same arson case. The victim is a 40-year-old woman. On arrival at A&E, she is conscious with no skin burns. She is tachypnoeic and wheezing. Stridor is not present.

    She is a victim of smoke inhalation. The emergency physician gives her oxygen and nebulized salbutamol 5 mg.

    Q1 What complications of smoke inhalation should you look in the initial phase of resuscitation?

    Meanwhile, a chest X-ray is taken. The SpO₂ as shown on the pulse oximeter is 99%. The PaO₂ is 13 kPa and PaCO₂ is 6 KPa.

    Q2 What do you expect...

  26. 23 Benzodiazepine overdose
    (pp. 46-47)

    Drug overdose is a common medical problem in A&E. One of the most common drugs used in overdose is sleeping pills. Sleeping pills do not only mean benzodiazepines.

    Q1 What other components or drugs can be found in sleeping pills.

    Usually these patients are admitted conscious.

    Q2 What major toxic effects of these drugs may result in death?

    Flumazenil is the antidote for the benzodiazepines and you should be familiar with this drug.

    Q3 Should you give this drug to every patient suspected of a sleeping pill overdose?

    1. The benzodiazepines are the drugs most commonly found in sleeping pills. The...

  27. 24 Confusion in head injury
    (pp. 48-49)

    One afternoon, a construction-site worker was brought to the department. The ambulance men said that the man had fallen from about ten feet to the ground. He had struggled a lot during the journey to the hospital.

    On arrival, the patient had no spontaneous eye-opening. He appeared confused and struggled against being examined. Chest examination was difficult, but there appeared to be adequate and symmetrical air entry. The blood pressure was 170/80 mmHg and pulse was 50 to 60/min. The abdomen was soft and not distended. Abrasion were noted on the right forehead with mild right periorbital swelling. His right...

  28. 25 Use of naloxone
    (pp. 50-51)

    A young man was brought unconscious to A&E. According to the ambulance crew, the patient was attending the rehabilitation centre because of an orthopaedic condition. It was reported that the young man had told the physiotherapist during a consultation that he had taken all the analgesics which he had been prescribed.

    On examination, the patient was unconscious. The pupils were reactive but small. The limbs were flaccid. The blood pressure and pulse were normal, but chest movement was barely noticeable. The SpO₂ was about 80%. The abdomen was soft.

    Q1 What is your first priority in the initial resuscitation of...

  29. 26 Fracture of the first rib
    (pp. 52-52)

    A colleague working in the surgical department once criticized our management of a patient who was a victim of a road traffic accident. The patient ultimately died and the surgeon’s criticism was of our underestimation of the severity of the injury. The patient had suffered a fracture of the first rib.

    Q1 Why is this injury important?

    1. Not only is a fracture of the first rib important but also that of the second rib. These two ribs are protected by the shoulder girdle and the strong muscles of the shoulder joint. Fracture of either one of these two ribs indicates...

  30. 27 Streptokinase and menstruating women
    (pp. 53-53)

    A 40-year-old woman presented to the department with central chest pain. She had been previously completely well. The examination was unremarkable except that she was in pain and she had started menstruating the day before. Her menstruation had been regular without any history of menorrhagia. ECG showed that she suffered from acute anterior myocardial infarction.

    Q1 Would her menses affect your decision to commence streptokinase treatment and why?

    1. Streptokinase should not be withheld in women during menses.

    Menstruation involves the shedding of endometrial tissues which are rendered ischaemic and necrotic by the constriction of the spiral arteries supplying the endometrium....

  31. 28 Back pain
    (pp. 54-55)

    Physical complaints of elderly patients are often vague and subtle. A 75-year-old man with a past history of hypertension presented at A&E with back pain. There was no definite history of trauma. He had had the back pain for several days and had already consulted A&E a few days earlier. He had been given an analgesic injection and then discharged with the diagnosis of osteoarthritic spine. However, the pain had seemed to get worse in the days that followed and so the patient came again.

    Examination showed no local tenderness in his spine, but the abdomen was diffusely tender. A...

  32. 29 Hypotension in myocardial infarction
    (pp. 56-57)

    A 65-year-old patient with a history of ischaemic heart disease was admitted for persistent chest pain. The pain was not relieved after four tablets of TNG. His blood pressure and pulse were within normal range and his chest was clear. ECG showed acute inferior myocardial infarction. The A&E medical officer decided to give the patient streptokinase, as there was no contraindication. While the streptokinase was being prepared, the patient’s blood pressure fell to 80/60 mmHg and the pulse was about 100/min.

    Q1 What should be the next action?

    Q2 Why did this patient’s blood pressure fall?

    1. Inferior myocardial infarction may...

  33. 30 Pseudocoma
    (pp. 58-59)

    If you work long enough in the A&E department, you are bound to see one or more cases with a really bizarre, baffling presentation. Sometimes the patient is labelled as a malingerer or hysterical, especially when there is no abnormal physical sign and the history given by the patient does not fit any clinical disease entity.

    Q1 Have you thought of the meaning of these words when you use them?

    There was a young man who presented with coma some time ago. He was subsequently found to be suffering from a psychiatric illness. The exact psychopathology of this patient was...

  34. 31 Capnography
    (pp. 60-61)

    Advances in technology accompany the expansion of emergency medicine. In the resuscitation room, there is a small device for the measurement of end-tidal CO₂. The measurement is depicted in the form of a graph.

    Q1 Do you know the normal shape of the graph?

    In the normal situation, there is virtually complete equilibration of CO₂ at the alveolar-capillary interface at the end of expiration. Thus, you can deduce that the level depends on the rate of removal of CO₂ i.e. ventilation, and the rate of production, i.e. pulmonary blood flow, and therefore cardiac output.

    Q2 What clinical conditions would affect...

  35. 32 Refractory ventricular fibrillation
    (pp. 62-63)

    The sound of the ambulance siren was getting louder and louder. It heralded the arrival of a middle-aged man who had collapsed in the street. The patient was in cardiac arrest and the cardiac monitor showed ventricular fibrillation.

    Treatment in line with American Heart Association guidelines was immediately instituted. The A&E medical officer had been taught in his induction course that the prognosis in ventricular fibrillation is good and that the most effective initial treatment is defibrillation. However, in this patient, ventricular fibrillation persisted despite drugs and defibrillation.

    Q1 What advice would you give the A&E medical officer in dealing...

  36. 33 Ethics on resuscitation
    (pp. 64-65)

    The A&E medical officer managed to control the ventricular fibrillation of the patient in the previous case. However, the rhythm was idioventricular and there was no spontaneous cardiac output. Resuscitation had been continued for 40 minutes. The patient’s relatives had arrived. They requested withdrawal of treatment as the patient’s pre-morbid state was poor and he depended on others to look after him.

    Q1 Would you continue or discontinue treatment?

    1. Obviously, there is no standard answer to the question. Personal experience and learning plays a significant role in the decision-making process. I remember when I was a houseman, I had to...

  37. 34 Spinal cord injury
    (pp. 66-67)

    ‘Mind the platform gap’ seems to be broadcast so frequently in mass transit railwa y stations that we tend to ignore the message. Misfortune, however, comes unexpectedly. A middleaged man was sent to A&E with a neck injury. He had misjudged the gap on an railway station platform while alighting. He hit his chin on the ground first and his neck sustained a hyperextension injury.

    His neck was not noticeably tender, as he said that he said that he suffered from neck pain anyway. His limbs, however, were weak with brisk reflexes.

    Q1 What do you think has happened to...

  38. 35 Human bite wounds
    (pp. 68-69)

    An assault case. A man who was both a victim of an assault and an assailant came to the department with an injury of the right hand. He had hit somebody in the face and injured his hand on the victim’s teeth in the process. You examine him and find a laceration across the third and fourth metacarpophalangeal joint region.

    Q1 Would you suture this wound and why?

    The patient asks you if he needs any blood tests for AIDS or other infectious diseases.

    Q2 What would be your answer?

    You decide to give this man an antibiotic.

    Q3 What...

  39. 36 Sternoclavicular joint dislocation
    (pp. 70-71)

    A young athlete complained of right shoulder pain after a fall. He had tripped and fallen on his right shoulder while running. Examination revealed diffuse tenderness of the shoulder which limited all ranges of movement in his right arm. He had to flex his neck to the right side to avoid exacerbating the pain. X-ray of the shoulder and the clavicle was normal. He was given an arm sling and discharged. However, he returned some hours later with dyspnoea and numbness of his right arm. This time you see him.

    Q1 What injury do you suspect was missed in the...

  40. 37 Non-accidental injury
    (pp. 72-73)

    A young mother came to A&E one morning with her three-month-old son saying that the baby had fallen accidentally from his cot and injured his left arm. The emergency physician examined the baby and found that the upper arm was swollen. The child became irritabl e whenever the upper arm was touched. The doctor ordered an X-ray which showed a spiral fracture of the shaft of the humerus.

    Q1 Any suspicion in your mind concerning the X-ray finding?

    The emergency physician proceeded with a detailed examination of the baby and found no other injuries.

    Q2 How would you deal with...

  41. 38 HIV exposure in health-care workers
    (pp. 74-76)

    HIV transmission in the health-care setting is an important topic as the number of HIV-infected persons is rising and it seems that we do not have an effective means to withhold its spread.

    Q1 Do you know the commonest mode of HIV transmission in the health-care setting?

    Q2 Is there any special form of wound treatment after exposure to HIV?

    Q3 How often should serological blood tests be done post-exposure?

    Should you give all exposed health-care workers post-exposure antiviral prophylactic treatment?

    1. The commonest mode of transmission is by percutaneous injury, of which needle-prick is the most frequently encountered. The estimated...

  42. 39 Some questions on AIDS
    (pp. 77-77)

    Jome more questions on AIDS that are related to the practice of emergency medicine.

    Q1 What are the commonest forms of presentation of AIDS in A&E?

    Q2 Should you give antitetanus toxoid to an AIDS patients with wounds?

    Q3 What does fever signify in HIV-infected persons?

    Q4 Should active resuscitation be instituted in advanced AIDS patients?

    1. AIDS is likely to present in A&E as opportunistic infections or complications related to its drug treatment.

    2. Giving antitetanus toxoid is not contraindicated in HIV-infected patients.

    3. Fever in HTV infected patients indicates:

    (a) Systemic infection.

    (b) HTV related fever.

    (c) Malignancy, e.g. Hodgkin’s lymphoma....

  43. 40 Abdominal injury
    (pp. 78-79)

    A victim of car crash was transferred to your hospital from another hospital. According to the referral notes, the patient had suffered a serious head injury with an initial GCS of 3/15. He was intubated and two IV lines secured. X-rays of the chest, lateral cervical spine and the pelvis were normal.

    On arrival, the GCS was still the same. The wound on the scalp was dressed and bleeding controlled. No other superficial injuries were noted. The blood pressure, however, dropped from 130/80 mmHg before transfer to 80/40 mmHg and the pulse was 110/min.

    Q1 Why did the blood pressure...

  44. 41 Trauma score
    (pp. 80-81)

    Trauma score is an important topic in emergency medicine.

    Q1 What is the trauma score system?

    The system proposed for use in the A&E department is ‘trauma score’. It measures the respiratory rate, systolic blood pressure, GCS, capillary refill and the respiratory expansion. The range of the score is from 1 to 16. The higher the score the less severe the injury.

    Q2 What are the drawbacks of this system?

    Q3 When the trauma score of a patient is 16, does it mean that his injury is the least severe and why?

    1. The trauma score is a numerical system that...

  45. 42 Oxygen therapy
    (pp. 82-83)

    Do you know which drug is most extensively used in the A&E department? Buscopan? Toradol? No, it is oxygen.

    Oxygen is not a prescription drug. It is almost always given using a face mask by the nurse before the patient is assessed by the medical officer.

    Q1 Should oxygen be given to every patient presenting to A&E?

    As an alternative to the face mask, a nasal cannula can be used to give oxygen. It may be a better route of administration, although the method is not often used.

    Q2 Before it is adopted, do you know how it works?


  46. 43 Adolescent pregnancy
    (pp. 84-85)

    A previously healthy 16-year-old girl presented to A&E with low back pain. There was no history of trauma and the pain had come on gradually with increasing severity. She denied any systemic symptoms, but said that she was menstruating.

    On examination, she was obviously overweight. The abdomen was soft and there was no local spinal tenderness.

    Q1 What diagnosis comes to mind?

    The A&E medical officer was puzzled by this patient’s presentation. On further questioning, she described the back pain as if something was pushing down and mentioned that her menses were lighter than usual.

    Q2 Would you change your...

  47. 44 Digoxin toxicity
    (pp. 86-87)

    A young woman was admitted after attempting suicide by swallowing 50 tablets of digoxi n 0.25 mg 1 hour prior to presentation. In A&E, she was fully alert with normal haemodynamics. Gastric lavage was performed.

    Q1 What precaution should you take during the procedure with respect to digoxin overdose?

    At the same time, her sodium/potassium level was checked.

    Q2 What is the purpose of checking the electrolytes and how do you manage them if they are abnormal?

    Arrhythmias are common in digoxin overdose and may require treatment in the A&E department.

    Q3 What are they and what precautions should be...

  48. 45 Litigation in emergency medicine
    (pp. 88-89)

    If you work long enough in hospital, dealing with patients’ complaints is almost unavoidable. Risk management refers to the identification and rectification of situations that may put the doctor at risk. In the US, emergency medicine is among the specialties which top the litigation stakes. Thus, risk identification in A&E is particularly important. Knowledge and care are essential. But how you write your medical record is also very important.

    There is a useful book which outlines seven common deficiencies in medical records.

    Q1 Do you know them?

    If you know them all, you probably can skip this quiz.

    1. The seven...

  49. 46 Pacing in bradycardia
    (pp. 90-91)

    An 80-year-old patient with a history of ischaemic heart disease was admitted because of drowsiness. Her drug compliance was satisfactory. The patient could not offer any specific complaints when the A&E medical officer attempted to take a history. Examination of the neurological system did not provide any useful clues as to the cause of drowsiness, nor did examination of the chest and abdomen. Her blood pressure was 120/80 mmHg and pulse was 30/min. ECG showed sinus bradycardia. BM stix was normal.

    The A&E medical officer thought that the drowsiness was caused by the bradycardia.

    Q1 Do you think the bradycardia...

  50. 47 Breaking bad news
    (pp. 92-93)

    A&E work is often interspersed with life and death drama. Unfortunately, in a typical A&E department, the sorrow of death is much more common than the joy of the birth of a new life. Every now and then one has to break bad news to the deceased’s relatives. For most of us, it takes only a few minutes and the relatives are then directed to see the body of the dead person. We are relieved, but the relatives are not.

    What you say to the relatives immediately after the death of a loved one may be critical to the development...

  51. 48 A drunk patient
    (pp. 94-95)

    A middle-aged well-dressed businessman was brought to A&E by some friends. They all smelled of alcohol. They said that the patient had just drunk a little more than usual and bumped his head against a wall on leaving a bar a few hours earlier.

    Examination did not reveal any scalp wound or other significant injury. The patient was conscious and oriented. Actually, the patient was very amiable and was joking with the nurses and other people in the waiting area. The A&E medical officer carried out a BM stix test and skull X-ray. Both were normal. The patient and his...

  52. 49 Pre-hospital trauma care
    (pp. 96-97)

    One sunny Sunday, the A&E medical officer drove with friends to the countryside. On the way, they witnessed a traffic accident, a crash between two cars. The driver of one of the cars was protected from injury by an airbag. But the passengers in the other car were thrown out. Two of them were all right and were on their feet and moving. One girl, however, lay semiconscious on the ground. The A&E medical officer’s friend, who was a surgical medical officer, ran to the girl and put her in the recovery position with the help of passers-by. In a...

  53. 50 Pulse oximetry
    (pp. 98-99)

    Pulse oximetry is probably the greatest advance in patient monitoring since electrocardiography. It is widely used in our department during the resuscitation of critically ill patients. It works according to the principle of differential light absorption by oxygenated and reduced haemoglobin.

    Q1 Why does it incorporate ‘pulse’ in its measurement, in addition to indicating the pulse rate?

    The pulse oximeter is better than the human eye in detecting hypoxaemia. The influence of hypoxaemia on patients varies.

    Q2 At what value of SpO₂ should one set the alarm?

    Q3 As there are so many advantages of pulse oximetry, can it replace...

  54. 51 Gastrointestinal decontamination
    (pp. 100-101)

    A 40-year-old woman was admitted to A&E after ingesting 30 tablets of lorazepam. She had taken the drugs about 3 hours before her arrival at the department. She was fully conscious with normal vital signs. Gastric lavage was performed in the department.

    A teenage girl presented to A&E having shortly before ingested an unknown amount of insecticide. She was alert and showed no signs of cholinergic toxicity. She was given 30 ml of ipecacuanha and directly admitted to the medical ward.

    Q1 Do you agree with the treatments given?

    1. The toxic-therapeutic ratio of the benzodiazepines is very high and death...

  55. 52 Paediatric cardiorespiratory arrest
    (pp. 102-103)

    A 13-year-old girl with mild-grade mental deficiency was admitted in cardiorespiratory arrest and her ECG showed asystole. Her parents said that she had previously been in good health, but that on the morning of the day of presentation she showed symptoms of a flu. She had complained of dizziness the previous evening and went to bed. She woke with dyspnoea and shortly afterwards collapsed.

    Cardiopulmonary resuscitation had been performed by the paramedics and an oral airway was already in situ when she was brought to the department. She was intubated and resuscitated according to AHA protocol. Physical examination showed no...

  56. 53 Stab wounds of the chest
    (pp. 104-105)

    A young man had been stabbed in the chest with a knife. He was not tachypnoeic when he arrived at the department and his vital signs were stable. The stab wound was to the right lateral chest wall in the region of the fifth intercostal space on the mid-axillary line.

    Q1 Does the site of the wound bear any significance to your management?

    The A&E medical officer arranged a chest X-ray and found no abnormality. He then explored the wound and it appeared that only subcutaneous fat was involved. He decided to suture the wound and the patient was discharged....

  57. 54 The vital signs in stroke
    (pp. 106-107)

    A 65-year-old man presented with acute hemiplegia. He had a history of hypertension and was taking nifedipine regularly. According to his accompanying relatives, his blood pressure had been under good control.

    When the A&E medical officer examined him, the patient was fully alert. He was febrile with a temperature of 37.8°C. His main neurological deficit was right hemiplegia. His blood pressure was 200/100 mmHg and the pulse was 85/min. Examination of the other body systems revealed no abnormalities. A bedside Hemostix test gave 10 mmol/L.

    Obviously, the clinical diagnosis was acute stroke.

    Q1 How would you manage his:

    (a) fever;...

  58. 55 Compartment syndrome
    (pp. 108-109)

    An 80-year-old woman was admitted with a right forearm injury. According to the old-aged-home staff who brought her in, the patient was found that morning, as they were preparing breakfast, lying on her right side on the floor. How long the patient had been there was not known. On examination, the patient showed signs of dementia, but was alert. The vital signs were all normal. There were no superficial injuries to the body except for some pressure marks on the right forearm. The arm was slightly swollen and tender. The radial pulses were equal. X-ray of the right forearm showed...

  59. 56 Anaphylaxis
    (pp. 110-111)

    An 11-year-old boy was admitted because of a generalized skin rash which had developed after eating seafood. He had a past history of asthma. His initial blood pressure was 75/50 mmHg. He was fully alert. There was diffuse erythema. He was tachypnoeic with rhonchi heard on chest auscultation. He was given IV chlorpheniramine 5 mg, IV hydrocortisone 100 mg and nebulized salbutamol 5 mg in the A&E department. He was then admitted to the ICU.

    Q1 What is the clinical diagnosis?

    Q2 What other symptoms or signs should be looked for and recorded in the notes?

    Q3 What additional interventions...

  60. 57 Necrotizing infection
    (pp. 112-113)

    A middle-aged woman presented with a painful and swollen right foot which she had had for two days. There was no history of trauma. She was not a diabetic. On examination, the foot was swollen, tender, erythemic and warm. There were two to three vesicles on the dorsum. Her general condition was good, although she had a temperature of 38.5°C.

    She was admitted with a provisional diagnosis of cellulitis. IV ampicillin and cloxacillin were administered. After 24 hours there had been no response to the antibiotics; she was still febrile and the right foot remained swollen and tender. She was...

  61. 58 Falls from heights
    (pp. 114-115)

    A young man was brought to the department after falling from scaffolding. He had been about 5 m from the ground when he fell. He had landed on his feet and complained of severe pain in both.

    Examination showed that his feet were swollen and diffusely tender. He was shouting with pain. The A&E medical officer gave him an analgesic injection and quickly arranged an X-ray of his feet. The X-ray did not reveal any fractures. Because of the severity of the pain, he was admitted to the observation room for pain relief.

    One hour later, the patient complained of...

  62. 59 Change in ABC
    (pp. 116-117)

    A young man presented in a coma with a drug overdose. The A&E medical officer decided to perform gastric lavage. He proceeded first to intubate the patient using rapid sequence induction using thiopentone and suxamethonium. The procedure went smoothly and quickly. The patient was then manually ventilated with an ambubag.

    However, while the nurses were preparing the equipment for lavage, the patient became cyanotic and the SpO₂ dropped from 100% to 70%. He also developed hypotension and tachycardia.

    Q1 What steps should be used to approach this problem?

    While the A&E medical officer was examining the patient, he noticed subcutaneous...

  63. 60 Streptokinase in myocardial infarction
    (pp. 118-119)

    The decision to give streptokinase to patients with acute myocardial infarction (AMI) in the emergency setting is not an easy one despite the availability of a protocol. Recently, a colleague raised the question of whether streptokinase should be given to an AMI patient whose ECG had aheady shown deep Q waves. The history is as follows.

    A 77-year-old patient, in previous good health, presented with a 6-hour history of chest pain. The ECG suggested an inferior AMI. ST segments were elevated 1 mm in the inferior leads and deep Q waves had already formed. Reciprocal ST changes in the other...

  64. 61 RV infarction
    (pp. 120-121)

    The patient from case 60 with acute inferior myocardial infarction, was given a tablet of TNG and a 10 mg nitrodisc patch. His blood pressure dropped from 120/80 mmHg to 80/40 mmHg. His lungs were clear. Streptokinase had not been started.

    Q1 What is the likely cause for the drop in blood pressure?

    Q2 What actions should be taken?

    1. The likely cause for the drop in blood pressure is right ventricular infarction in addition to inferior infarction. Hypotension precipitated by nitroglycerin use is characteristic of right ventricular infarction. In right ventricular infarction, the compliance of the right ventricle (RV) is...

  65. 62 Post-coital headache
    (pp. 122-123)

    Sex has some recreational value. But it is not always fun, especially when it becomes a headache. A young man, recently married, presented to the emergency department because of headache while having coitus with his wife. He appeared tense and complained of a diffuse cramping pain in the head.

    Q1 How would you evaluate his headache with regard to his sexual activity?

    1. It is helpful to correlate the time of onset of headache with orgasm.

    Pre-orgasmic headache is usually associated with a space-occupying lesion of the intracranial cavity.

    Orgasmic headache is often severe and the important diagnosis to consider is...

  66. 63 Foreign-body ingestion
    (pp. 124-125)

    One evening, a mother brought in her eight-year-old child. She explained that the boy had swallowed a fish bone. He told his mother that the bone was stuck in his throat. There was no haemoptysis or haematemesis.

    The A&E medical officer examined the child’s throat, but could find no bone. The only positive finding was an abrasion on the soft palate. X-ray of the neck did not reveal any radio-opaque foreign body or soft tissue swelling. The child was later admitted to the surgical ward. He was discharged the next day after a negative upper endoscopy. However, he presented again...

  67. 64 ALTE
    (pp. 126-127)

    An anxious mother brought her seven-day-old baby to A&E saying that the baby had suddenly turned blue while sleeping. The A&E medical officer examined the baby, who was now quite pink and sleeping quietly in its mother’s arms. There was some facial grimacing on stimulation. Its muscle tone was normal. The cardiorespiratory status was also normal. Realizing that the baby was all right, the anxious mother relaxed and gave a more detailed history.

    That afternoon, while the baby was sleeping on its side 1 hour after a milk feed, she heard it give a sudden cry. She ran immediately to...

  68. 65 Tall T wave on ECG
    (pp. 128-129)

    A 67-year-old man presented with first-time chest discomfort. The discomfort was pressure-like and radiated to his chin. On examination, he was sweating profusely. However, no other abnormal physical findings were noted. Below is his ECG.

    Q1 How should this ECG be interpreted?

    1. The ECG shows sinus rhythm. The most significant feature is the promment T waves in the V leads. A small Q wave with inverted T wave is also present in the inferior leads.

    This man was treated for acute coronary syndrome. Enzyme studies showed that he was suffermg from acute myocardial infarction.

    Quite a number of conditions can...

  69. 66 Status epilepticus and failed intubation
    (pp. 130-131)

    An epileptic patient presented to A&E in a state of convulsion which had lasted for more than 30 minutes. Immediate resuscitative measures were carried out. Diazepam 20 mg was given, but the convulsion persisted.

    Q1 What other drugs would you consider administering?

    After treatment, the patient’s respiratory effort was depressed. Intubation by rapid-sequence induction was decided upon before transfer to the ICU. But the intubation failed.

    Q2 What should you do then?

    Fortunately the patient was successfully intubated at the second attempt. He was then treated in the ICU.

    1. There are a number of drugs that may be useful:


  70. 67 Low back pain
    (pp. 132-133)

    Low back pain is a common reason for A&E attendance. Pain of a mechanical origin is usually worsened by activity and relieved by rest. Non-musculoskeletal conditions may mimic musculoskeletal low back pain.

    Q1 What are they?

    Most patients with low back pain do not have neurological signs like nerve entrapment. X-rays are frequently ordered but add little to management.

    Q2 What are the indications for lumbosacral spine X-ray in patients?

    1. Conditions to consider are:

    (a) Pulmonary disorders, e.g. pleural effusion.

    (b) Vascular problems, e.g. abdominal aortic aneurysm.

    (c) Gastrointestinal disorders, e.g. chronic pancreatitis.

    (d) Genitourinary disorders, e.g. pyelonephritis.

    Recently a...

  71. 68 Insomnia
    (pp. 134-135)

    A 17-year-old male presented with headache and insomnia. He had attended the A&E once earlier and was prescribed midazolam.

    Q1 What are the possible causes of insomnia in general?

    When he was seen for the second time, his history and physical examination offered no clues for his symptoms. His behavior, however, was peculiar in that he lacked affect and gave no direct eye contact throughout the interview. On direct questioning, he disclosed that he could not sleep because he was hearing non-existent voices. He was then referred to the psychiatric outpatient clinic.

    Q2 Is it safe to prescribe benzodiazepines in...

  72. 69 Non-surgicall causes of abdominal pain
    (pp. 136-137)

    A middle-aged woman presented with acute abdominal pain, vomiting and diarrhoea. Her past health had been good. Physical examination showed her to be pale and jaundiced. The abdomen was diffusely tender with no organomegaly. Urine tests for bile and urobilinogen were negative. SGOT was slightly elevated. Bedside haemoglobin measurement read 7.7 g/dL. Although her pain was relieved with Buscopan, she was admitted. A positive Coombs’ test was found on follow-up. Later, she developed acute renal failure as a result of haemolysis.

    Jaundice is not always due to hepatitis. Abdominal pain with vomiting and diarrhoea is not always due to gastroenteritis....

  73. 70 Fat embolism
    (pp. 138-139)

    A fit 22-year-old hiker slipped and fell down a slope about 3 m feet from his track. He sustained a broken right leg and could not move. He shouted for help, but was not heard until 12 hours later. The rescue team took 2 hours to take him to the A&E department.

    In A&E, he was fully alert with normal haemodynamics. His only injury appeared to be a closed fracture of the right femur with no neurovascular deficit. While X-rays were being taken, he was noted to be tachypnoeic and confused.

    Q1 What are the possible reasons for his sudden...

  74. 71 Re-expansion pulmonary edema
    (pp. 140-141)

    A 45-year-old woman presented to A&E with a five-day history of right chest pain.

    She had had two episodes of right pneumothorax in the past. Chest X-aray this time showed a right pneumothorax with complete collapse of the lung. As she was tachypnoeic and with her past history of recurrent pneumothorax, a 24F chest drain was inserted. Shortly after the procedure had been completed, she was found to be in respiratory distress, cyanosed, sweaty and with cold extremities. Her blood pressure was 100/60 mmHg and pulse was 100/min.

    Q1 What could have happened?

    Chest examination revealed right-sided crackles and occasional...

  75. 72 Chest pain in paediatrics
    (pp. 142-144)

    A 15-year-old boy presented with a one-week history of central chest pain. The pain began as mild left chest discomfort. It came on after a football game to which he attributed the discomfort. But it gradually worsened. Mild dizziness and nausea also developed. There was no fever and no history of upper respiratory tract infection. He had been completely well previously. Physical examination was normal, except for a borderline tachycardia of 102 beats per minute. ECG showed sinus rhythm. While the boy was being sent to the X-ray suite for chest X-ray, he suddenly collapsed and died, despite all efforts...

  76. Index
    (pp. 145-146)