Common Presentations (As in the ER)... By Shapi.pdf

EMERGENCY MEDICINE
• COMMON PRESENTATIONS
Dr. Chongo Shapi (BSc.HB, MBChB).
Medical Doctor
9 March 2024 1
Dr. Chongo Shapi (BSc. HB, MBChB)

HEADACHE
18 March 2024 Dr. Chongo Shapi (BSc. HB, MBChB) 2

HEADACHE
• The vast majority of headaches are benign, but when
taking a history do not forget to ask about the
following (early diagnosis can save lives):
a) First and worst headache—subarachnoid
haemorrhage.
b) Thunderclap headache—subarachnoid haemorrhage
c) Unilateral headache and eye pain—cluster headache,
acute glaucoma
d) Unilateral headache and ipsilateral symptoms—
migraine, tumour, vascular
e) Cough-initiated headache—Raised ICP/venous
thrombosis.

CONT’
f) Worse in the morning or bending forward—
Raised ICP/venous thrombosis
g) Persisting headache ± scalp tenderness in
over-50s—giant cell arteritis
h) Headache with fever or neck stiff ness—
meningitis
i) Change in the pattern of ‘usual headaches’
j) Decreased level of consciousness

CONT’
• Two other vital questions:
a) Where have you been? (Malaria).
b) Might you be pregnant? (Pre-eclampsia;
especially if proteinuria and Raised BP)
• Always examine a patient presenting with a
severe headache; if nothing about history or
examination is concerning, both you and the
patient will be reassured, but subtle
abnormalities are important not to miss.

CONT’
• No signs on examination?
a) Tension headache.
b) Migraine.
c) Cluster headache.
d) Post-traumatic.
e) Drugs (nitrates, calcium-channel antagonists)
f) Carbon monoxide poisoning or anoxia.
g) Subarachnoid haemorrhage.

CONT’
• Signs of meningism
a) Meningitis (may not have fever or rash).
b) Subarachnoid haemorrhage.
• Decreased conscious level or localizing signs?
a) Stroke.
b) Encephalitis/meningitis.
c) Cerebral abscess.
d) Subarachnoid haemorrhage.
e) Venous sinus occlusion (focal neurological deficits).
f) Tumour.
g) Subdural haematoma.
h) TB meningitis

CONT’
• Papilloedema?
• Tumour.
• Venous sinus occlusion (focal neurological
deficits).
• Malignant (accelerated phase) hypertension.
• Idiopathic intracranial hypertension (p498).
• Any CNS infection, if prolonged (eg >2wks)—
eg TB meningitis

CONT’
• Others
• Giant cell arteritis (Raised ESR and tender scalp over
temporal arteries).
• Acute glaucoma (painful red eye—get pressures
checked urgently).
• Vertebral artery dissection (neck pain and
cerebellar/medullary signs).
• Cervical spondylosis.
• Sinusitis.
• Paget’s disease (Raised ALP).
• Altitude sickness.

BREATHLESSNESS

BREATHLESSNESS
• There may not be time to ask or the patient
may not be able to give you a history in acute
breathlessness, this in itself can be a helpful
sign (inability to complete sentences in one
breath = severe breathlessness, inability to
speak/impaired conscious level = life-
threatening).

CONT’
• Collateral history of known respiratory disease,
anaphylaxis, or other history can be extremely
helpful but do not delay. Assess the patient for
the following:
• Wheezing?
a) Asthma.
b) COPD.
c) Heart failure.
d) Anaphylaxis.

CONT’
• Stridor? (Upper airway obstruction.)
a) Foreign body or tumour.
b) Acute epiglottitis (younger patients).
c) Anaphylaxis.
d) Trauma, eg laryngeal fracture.
• Crepitations?
a) Heart failure.
b) Pneumonia.
c) Bronchiectasis.
d) Fibrosis.

CONT’
• Chest clear?
a) Pulmonary embolism.
b) Hyperventilation.
c) Metabolic acidosis, eg diabetic ketoacidosis.
d) Anaemia.
e) Drugs, eg salicylates.
f) Shock (may cause ‘air hunger’,).
g) Pneumocystis jirovecii pneumonia.
h) CNS causes.

CONT’
• Others
a) Pneumothorax (pain, increased resonance,
tracheal deviation if tension pneumothorax).
b) Pleural effusion (‘stony dullness’).

CONT’
• Key investigations
a) Baseline observations—O2 sats, pulse,
temperature, peak flow.
b) ABG if saturations <94% or concern about
acidosis/drugs/sepsis.
c) ECG (signs of PE, LVH, MI?).
d) CXR.
e) Baseline bloods: Glucose, FBC, U&E, consider
drug screen.

CHEST PAIN

CHEST PAIN
• First exclude any potentially life-threatening causes, by
virtue of history, brief examination, and limited
investigations. Then consider other potential causes.
• Life-threatening
a) Acute myocardial infarction.
b) Angina/acute coronary syndrome.
c) Aortic dissection.
d) Tension pneumothorax.
e) Pulmonary embolism.
f) Oesophageal rupture.

CONT’
• Others
a) Pneumonia.
b) Chest wall pain:
c) Muscular.
d) Rib fractures.
e) Bony metastases.
f) Costochondritis.
g) Gastro-oesophageal reflux.
h) Pleurisy.

CONT’
h) Empyema.
I) Pericarditis.
J) Oesophageal spasm.
K) Herpes zoster.
L) Cervical spondylosis.
• Intra-abdominal
N) Cholecystitis.
O) Peptic ulceration.
P) Pancreatitis.
Q) Sickle-cell crisis.

CONT’
• Before discharging patients with undiagnosed
chest pain, be sure in your own mind that the
pain is not cardiac (this pain is usually dull, may
radiate to jaw, arm, or epigastrium, and is usually
associated with exertion).
• Carry out key investigations and discuss options
with a colleague, and the patient. Safety-net,
telling the patient to return or seek advice if they
develop worrying features (specify these) or the
pain does not settle.

CONT’
• Key investigations
a) CXR.
b) ECG.
c) FBC, U&E, and troponin. Consider D-dimer
only if low probability of venous
thromboembolism. See 'Modified Wells'
score for PE.

CONT’
• Just because the patient’s chest wall is tender
to palpation, this doesn’t mean the cause of
the chest pain is musculoskeletal.
• Even if palpation reproduces the same type of
pain, ensure that you exclude all potential life-
threatening causes.
• Although chest wall tenderness has
discriminatory value against cardiac pain, it
may be a feature of a pulmonary embolism.

COMA

COMA
• Definition: Unrousable unresponsiveness. Quantify using
Glasgow Coma Scale (GCS).
• Metabolic:
a) Drugs, poisoning, eg carbon monoxide, alcohol, tricyclics.
b) Hypoglycaemia, hyperglycaemia (ketoacidotic, or HONK).
c) Hypoxia, CO2 narcosis (COPD).
d) Septicaemia.
e) Hypothermia.
f) Myxoedema, Addisonian crisis.
g) Hepatic/uraemic encephalopathy.

COMA
• Neurological:
a) Trauma.
b) Infection: meningitis; encephalitis (eg herpes
simplex), tropical: malaria; (do thick films),
typhoid, typhus, rabies, trypanosomiasis.
c) Tumour: 1° or 2°.
d) Vascular: stroke, subdural, subarachnoid,
hypertensive encephalopathy.
e) Epilepsy: non-convulsive status or post-ictal
state.

COMA MANAGEMENT
• Assess Airway, Breathing, and Circulation.
Consider intubation if GCS <8. Support
• the circulation if required (i.e IV fluids). Give O2
and treat any seizures. Protect the cervical spine
unless trauma is known not to be the cause.
• Check blood glucose; give eg 200mL 10% glucose
IV stat if hypoglycaemia possible.
• IV thiamine if any suggestion of Wernicke’s
encephalopathy

MANAGEMENT CONT’
• IV naloxone (0.4–2mg IV) for opiate
intoxication (may also be given IM or via ET-
tube); IV flumazenil (p842) for benzodiazepine
intoxication only if airway compromised as risk
of seizures especially if concomitant tricyclic
intoxication.

EXAMINATION
• Vital signs are vital—obtain full set, including
temperature.
• Signs of trauma—haematoma, laceration, bruising,
CSF/blood in nose or ears, fracture ‘step’ deformity of
skull, subcutaneous emphysema, ‘panda eyes’.
• Stigmata of other illnesses: liver disease, alcoholism,
diabetes, myxoedema.
• Skin for needle marks, cyanosis, pallor, rash
(meningitis; typhus), poor turgor.
• Smell the breath (alcohol, hepatic fetor, ketosis,
uraemia).

CONT’
• Opisthotonus ≈meningitis or tetanus. Decerebrate/decorticate
• Meningism: but do not move neck unless cervical spine is cleared.
• Pupils size, reactivity, gaze.
• Heart/lung exam for BP, murmurs, rubs, wheeze, consolidation,
collapse.
• Abdomen/rectal for organomegaly, ascites, bruising, peritonism,
melaena.
• Are there any foci of infection (abscesses, bites, middle ear
infection)?
• Any features of meningitis: neck stiff ness, rash, focal neurology?
• Note the absence of signs, eg no pin-point pupils in a known heroin
addict.

QUICK HISTORY
• From family, ambulance staff , bystanders: abrupt or
gradual onset?
• How found—suicide note, seizure? If injured, suspect
cervical spinal injury and do not
• move spine. Recent complaints—headache, fever,
vertigo, depression?
• Recent medical history—sinusitis, otitis, neurosurgery,
ENT procedure? Past medical history—diabetes,
asthma, HTN, cancer, epilepsy, psychiatric illness? Drug
or toxin exposure (especially alcohol or other
recreational drugs)? Any travel?

Thanks

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