Transcript SAQ Spot Diagnosis

Fellowship Revision
2016
Case 1
CXR – Cyanosis, Hypotension
List two findings on this CXR
• Low ETT
• Widened Mediastinum
Differentials
• Retrosternal goitre
• Thymoma
• Lymphadenopathy (e.g. lymphoma)
• Lipoma
• Neurogenic tumour (e.g. neurofibroma)
Case 2
CT – Reduced LOC
Hydrocephalus
• In general terms, hydrocephalus is due to
impaired CSF flow, impaired CSF reabsorption
or excessive CSF production
Hydrocephalus
• Communicating (non-obstructive)
– normal-pressure hydrocephalus, hydrocephalus
ex vacuo (enlargement of the CSF spaces due to
brain atrophy)
• Non-communicating (obstructive)
– tumours, haemorrhage, basal meningitis,
congenital abnormalities (e.g. spina bifida,
Arnold-Chiari or Dandy-Walker malformations)
Causes of LOC – Structural v Metabolic
Alcohol
Uraemia and
Trauma
Toxins
Hypertension
Infection
Oxygen
Psychogenic
Opiates
Porphyria
Endocrine
Encephalopathy
Insulin
Electrolytes
(Diabetes)
Seizure
Syncope
SOL (Mass)
Case 3
MCQ
Hydrofluoric Acid Burns
Case 4
• A 71 year old hostel resident is brought in
with a fever
• He is brought to ED with a reduced level of
consciousness and the GP had started
Augmentin the same morning but the patient
was unable to take the first dose in the
afternoon…
• He has a history of Diabetes, Ischamic Heart
Disease, Chronic Lung Disease and CCF
Na 130
K 6.1
Phos 1.1
Ca 2.9
Mg 0.9
WCC 22
HB 101
MCV 90
PLT 195
Urea 20
Cr 300
CRP 191
Digoxin Poisoning
Digoxin Poisoning
• What are the Clinical Features?
– Nausea, Vomiting, Hypokalaemia, Fatigue, Visual
Changes
– Heart Blocks, Bradycardia, VT/VF,
– Automaticity Increase
• What are the Indications for FAB?
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High K
Ingestion of more than 10mg
Haemodynamically Unstable
Cardiac Arrest after Digoxin Ingestion
Serum Dig Level of >15nmo/L
Case 5
Fall from Roof
• A middle aged man falls from a roof onto their
face…
• A CT scan is taken of his facial injury
Questions
• What are the findings on this Coronal CT?
• Describe a Classification System for Facial
Factures
• Describe the management of severe epistaxis
in this patient
Case 6
New Case
• A middle aged man presents with intermittent
abdominal pain on a background of recurrent
hospital presentations with Epigastric pain
Chronic Pancreatitis
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Persistent abdominal pain
Steatorrhoea from fat malabsorption
Weight loss
Secondary diabetes mellitus
Causes
• Chronic alcohol intake (at least 70%)
• Idiopathic (up to 25%)
• Cystic fibrosis (most common cause in young
patients)
• Rarely
– sphincter of Oddi dysfunction, chronic steroid or
anti-inflammatory use, autoimmune
Case 7
CT Chest - SOB
CT
• Linear filling defect in the pulmonary trunk
extending into the right and left main
pulmonary arteries consistent with a ‘saddle’
pulmonary embolism
PE
• List the ECG Changes associated
• List the indications for consideration of
Thrombolysis
• List the absolute and relative
contraindications to Thrombolysis
• Write a protocol for ruling out PE in patients
for your ED
Guideline Plan
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Rationale
Background
Target
Recommendations
Investigations and Management Issues
Special Circumstances
(K)wality Improvement (CQI) (Quality Assurance)
Governance Issues
References and Cited Literature
Incident Management (follow up of adverse events related
to policy)
• Dissemination of Guideline
Case 8
New Patient
• Young Man collapses during a training exercise
on a hot day.
• Bloods are as follows…
Questions
• What are the Key Findings
• What is the most likely diagnosis
• List 5 causes
Causes - TEASED
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Trauma
Excessive temperature or extreme Illness
Alcohol
Snake bite
Exercise
Drugs (especially amphetamines)
• Other
– Seizures
– Inflammatory myopathies (e.g. viral, autoimmune)
Case 9
Assessment
What is ALTE
• Define ATLE
• Common causes – write down 6
• Typical presentation – write down 4 points
Presentation
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Apnoea
Chocking
Frightening Episode
Muscle Tone Change
Change in Colour
Gagging
Observer feels the child has died
Recovery
Causes of ALTE
• Key Issue
– in an ALTE scenario ruling out sepsis and admission for
observation would the priority
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Idiopathic (50% of cases)
GORD (common but overly attributed)
Respiratory Infections (esp. Pertussis)
RSV, URTI, LRTI
Seizure
Metabolic (i.e. MCADD, Electrolytes)
UTI
Other (NAI, Tumour, Hypocalcaemia, Toxins, Opioid, SVT,
PDA, Gastroenteritis) Periodic (benign) breathing
THE MISFITS
Write down Paediatric Dose for:
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Adrenaline
Amiodarone
Atropine
Calcium
Glucose
Lignocaine
Magnesium
Potassium
Sodium Bicarbonate
Case 10
CT - Brought in by Police with Abdo
Pain
CT
• Appearance - Multiple abnormal hyperdense
foreign bodies in the stomach
• Possible causes - The foreign bodies are
consistent with the finding of drug packets
(classically, latex balloons) used to internally
transport illicit drugs, most frequently heroin
and cocaine (body packing by ‘drug mules’).
Both of these agents can cause cardiac arrest
if systemically absorbed.
CXR SOB
CXR – Pulmonary Oedema
• cardiogenic pulmonary oedema
– more common in a patient with sternal wires
evident
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non-cardiogenic pulmonary oedema (ARDS)
TRALI
infection
alveolar haemorrhage
proteinosis
Case 11
FOOSH
Management
• Describe how you would reduce this injury in
the Emergency Department
• Which patients are not appropriate for
procedural sedation in the ED setting?
Case 12
CT
CT Appearance
• Diffuse cerebral oedema as evidenced by loss
of grey-white differentiation with no
discernible sulci-gyri patterns and obliteration
of the ventricular system
Cerebral Oedema
• Vasogenic oedema
– breakdown of blood–brain barrier (e.g. trauma, hypoxiaischaemia, hypertensive encephalopathy, high altitude)
• Cytotoxic oedema
– impaired glial cell membrane pump function (e.g. toxins
such as isoniazid, early stroke or hypoxia-ischaemia, Reye’s
syndrome, severe hypothermia)
• Osmotic oedema
– sudden plasma dilution after prolonged generalised
hyperosmolality (e.g. during over-rapid correction of
hyperglycaemia in hyperosmolar hyperglycaemic state)
Interstitial oedema is unlikely as it is due to CSF–brain
barrier breakdown
Summary
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Mediastinum Enlargement
Hydrocephalus and Reduced LOC
Hydrofluoric Acid
Digoxin Toxicity
Head and Facial Trauma, Epistaxis
Pancreatitis
PE and Administration
ALTE
Body Packers
Wrist Injuries
Cerebral Oedema