A&E: Orientation

Question 1

Causes cannot afford to miss

Answer 1

1. Chest pain: Aortic dissection, AMI, PE
2. Abdominal pain: Leaking AAA
3. SOB: PE
4. Cut wound over limb: Nerve / Tendon cut
5. Headache: SAH
6. Vaginal bleeding: Ectopic pregnancy
7. Coma in a child: Shaken baby syndrome

Question 2

Targeted history

Answer 2

Electronic patient record in CMS is a good place to start

1. Chief complaint
2. HPI
   - Relevant positive + negative symptoms (e.g. LOC in head injury, Tarry stool in dizziness)
3. Past medical history
4. Current medication (e.g. Warfarin)
5. Drug allergy / Adverse reaction

Question 3

Focused P/E

Answer 3

Comprehensiveness vs Time constraint

• Always rmb to look at vital signs recorded by triage nurse
• Look for signs based on presentation (e.g. sprain ankle, cut finger)
• Rmb to check signs of important diagnoses for the presenting problem
  —> BP / Pulse both arms for chest pain suspecting Aortic dissection
  —> Cerebellar signs for dizziness / vertigo

Question 4

Symptomatic treatment

Answer 4

Often started pending investigations results
- Analgesics for pain control
- Anti-vertigo agent for dizziness
- Splinting for fracture / dislocation

Treatment can be a therapeutic trial
- Narcan (Naloxone) for coma suspecting opioid overdose
- Congentin (Benzatropine) for dystonic reaction

Question 5

Investigations

Answer 5

• Not every patient need investigations
• Based on working diagnosis (e.g. USG for gallstones)

Purpose:
1. Rule in (e.g. ECG for AMI: high specificity, X-ray for fracture)
2. Rule out (e.g. Troponin: high sensitivity)

Some are initiated by Triage nurse per protocol:
1. ECG for ACS
2. Blood for glucose
3. Urine: glucose, albumin, WBC, RBC, nitrite, HCG
4. USG: bladder scan for AROU

Common investigations:
Blood:
1. CBP
2. LRFT, glucose, amylase, urate
3. Troponin
4. D-dimer
5. ABG, VBG
6. Blood level for paracetamol etc.

Urine:
1. Microscopy
2. Culture
3. Toxicology screen

Imaging:
1. Plain X-ray
- Trauma (e.g. dislocation, fracture)
- Non-trauma (e.g. pneumonia)

2. USG
   - Pelvic USG for complications of pregnancy
   - Abdominal USG for gallstones, AAA, kidney stone
   - FAST scan for trauma
3. CT
   - Head CT for stroke
   - Thoracic CT for aortic dissection

Question 6

Pitfall leading to misdiagnosis

Answer 6

1. Misled by history
   - Atypical presentation (e.g. AMI presenting as throat discomfort)
   - Demented bed bound patient with knee swelling / no injury —> Knee fracture
2. Incomplete P/E
   - Missed nerve / tendon injury in cut wound
3. Misinterpretation of tests
   - Missed fracture
   - Missed subtle MI in ECG
4. Rare condition
   - Cerebral venous thrombosis with mild headache

Question 7

Treatment options

Answer 7

1. Supportive
   - Measure to support ABC
2. Symptomatic
   - e.g. Analgesics
3. Definitive
   - Suturing for wound
   - Closed reduction for dislocation
   - Drainage for abscess
   - Antibiotics for UTI