Clinical ed cases (8 2-12)

Clinical Cases
Miscellaneous ED presentations
Port Hedland – Rural Clinical School tutorial (8/2/12)

Dr Bishan Rajapakse

DrBish – Miscellaneous ED case presentations

Renal failure and back pain
 49 yo man end stage renal failure
 On dialysis times a week
 Fall 4 weeks ago – back pain and
lower leg pain since – walking with
limp, uses a stick
 OE// Tender in L upper thigh, lower
lumbar spine


 Describe what is seen on the Xray?
 What is your differential diagnosis?
 What further investigations do you
want?


 CT scan of the abdomen showed
changes consistent with renal
osteodystrophy
 ESR was not raised


Red eyes and abnormal
Cornea
 11 yo boy with 3 day history of
bilateral red eyes (worse on L)
 Treated for viral conjunctivitis with
Chloracetmycin drops but not
improving
 Visual acuity in L eye 6/18 R eye 6/6
 Diffuse Fluoroscein uptake


Nb vertical line is light reflex
 Describe what you see?


 What can be the cause of this
appearance?
 What is your plan?


 Ophthalmology consulted
◦ Likely to be viral conjunctivitis
◦ Chloramphenicol drops further irritant to
cornea resulting in oedma and swelling
◦ Treat viral conjunctivitis stop antibiotic
drops and continue with sterile lubricant
 Review in 24 hours
 Urgent referral if no improvement


Nb Visual acuity was 6/6 at follow up, patient improved


Ankle pain without trauma
 38 yo with painful swollen Ankle
 2 day history, no trauma reported
 Progressively worse yesterday
 Today unable to walk without limp


 What is your differential diagnosis
 Describe the ankle x-rays
◦ Is there anything to see?


Painful red eye…
 32 year old male with one day history
of painful red eye


 What is the likely diagnosis?


Chest abnormalities
 78 yo man presents with SOB to
provincial hospital ED


 What is your differential diagnosis?
 What is your plan?


 What was done?
 Describe what you see
 What is the diagnosis now?
 What else will need to be done?


Hand is hurting!


 What is the diagnosis?


 He was treated in a volar resting splint
 Comment on this treatment


Acute Breathlessness
 62 yo male truck driver acutely SOB –
BIBA as a category one to resus bay
◦ Transfer from airport after one hour flight
 Lips blue, RR 50, O2 sats 88% on RA
 Given oxygen
 Speaking in short sentences, some
chest tightness, no pain
 Doesn’t admit to previous lung
pathology

 What is the differential diagnosis?
 What other history will you ask for?
 What other investigations will you
order?


 Presumed malignancy with initial
differential as
 History of wt loss and haemoptysis
 This was first medical presentation
 Lung Ca confirmed on bronchial
washings – referred from respiratory
to oncology team


Abnormal CXR
 64 year old presents non-distressed
with epigastric discomfort


 What does this CT scan show?


 The patient has a ruptured diaphragm
with bowel herniation seen on CT


Child with distension?
 8 y.o. boy with history of development
delay
 Abdominal distension ++
 Pain requiring morphine
 Limited history from mother
◦ Suddenly became unwell in the last 2
hours


 What is the treatment?
 Do you know the diagnosis?


 He has a history of ingesting objects
on further questioning of mother
◦ Battery ingested
 Management
◦ Resuscitation and supportive cares
◦ Nasogastric to decompress the stomach,
referred urgently to paedsurg


 5 hours later after conservative Rx


Acute dysponea
 32 year old female presents with acute
dyspnoea 12 hours after a long haul
flight from Europe to Australia
 Saturations are 88% on RA, improve
with oxygen


 Multiple filling defects on CTPA
consistent with PE


Clinical ed cases (8 2-12)

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