Clinical Presentations IV Flashcards
How is trauma managed
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma), car trauma - speed, seatbelts, otehr people, what stopped the car?, full primary and secondary survey
Rx - analgesia prior to exam, treat injuries
How are soft tissue injuries managed (sprain and strains)
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma)
Ix - x-ray
Rx - POLICE
Protection
Optimal Loading - rest then weight bear once pain controlled
Ice to reduce swelling
Compression
Elevation to reduce pain and swelling
How are dislocations managed
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma)
Ix - x-ray
Rx -analgesia, document NV status, x-ray before and after reduction, recheck NV status, immobilize with strap, discharge with follow up and sling, may need physio
How are fractures managed
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma)
Ix - x-ray
Rx - analgesia only if rib or coccyx, ortho referral (imobilisation with backslab or sling with analgesia for most. If open, unstable or NV status compromised then ORIF)
How are open fractures managed
ABCDE
Senior help
Morphine
Take pictures before
Cover wound with iodeine or saline swabs
Start IV abx as per local guidelines
Review tetanus status
X-ray
Ortho referral urgent
How are wounds managed
S - mechanism of injury, bites, foriegn bodies, contamination, tetanus status, measure, check for distal NV compromise, CRT, movement
Ix - imaging make be required for foreign objects (x-ray)
Rx - clean would with 0.9% saline, if deeper wound may need syringe for higher pressure, closure - glue if small or on face, steri-strips can also be sed, if larger then LA intradermally and simple interupted stitches of non-absorbalbe sture can be often used, if deeper then may require absorbable sutures underneath to close other layers so get senior help if so.
When would a tetanus shot be given for wounds
Document tetanus status for all wounds
Ensure wound irrigation
>50yrs old and migrants may not have tetanus shots
Rx -
Full 5 injections <10yrs ago - no prophylaxis
Partial course <=10yrs ago - tetanus booster
Not immunised or unknown - start tetanus course
When are antibiotics given for wounds
Bites - co-amoxiclav or doxycycline if penicillin allergic
How is osteoporosis managed
S - bone pain, fragility fractures, arching back
Ix - DEXA scan and FRAX tool
Rx - Smoking cessation, regular weight breaing exercises, calcium and vitamin D, bisphosphonates
Bisphosphonates if fragility fracture or >75
How are head injuries managed
S - mechanism of injury, time of injury, memory loss, loss of conciousness, whitnesses, seizures, visual changes, AMPLE, fluid from vose or ears, vomiting, weakness or tingling in limbs, PMH clotting issues D+A anticouagulants SH baseline and occupation, Battles sign , haemotympanum, panda eyes, focal neurology, cause of fall? (syncope, hypoglycaemia)
Ix - CT head, routine bloods
Rx - admit if imaging abnormalities, GCS<15, worrying signs (vomiting, severe headache etc), intoxication
How are subdural haematomas managed
S - headache, decreased GCS and raised ICP, can be fluxuating if chronic, may have fall history, patients usually older, alcoholics and on anticoagulation
Ix - CT head
Rx - burrhole or crainotomy
How are patients with no concerning features post-head injury managed
Can be discharged home with support of a responsible adult for first 24hrs with head injury advice leaflet to explain the signs of deterioration and thus return to ED if they occur.
How are patients with extradural haematomas managed
S - headache, decreased GCS 4-8hrs post-fall and raised ICP, patients usually have trauma to head
Ix - CT head
Rx - craniotomy or burr hole
How are patients with post-concussion syndrome managed
S - headache, dizziness, tired, memory issues
Ix - CT head if meets criteria
Rx - no treatment
What are the criteria for a 1hr head CT
GCS <13 on initial assessment
GCS<15 2 hours post injury
Any sign of basal skull facture
Seizure
Focal neurology
>1 vomiting episode
What are the criteria for an 8hr head CT
> =65years old
Clotting disorder or blood thinners
Dangerous mechanism
Retrograde amnesia before the head injury
How are neck injuries managed
S - mechanism of injury, walking since accident, pain and SOCRATES, comfortable sitting, head injury, limb symptoms, AMPLE, previous beck problems or surgery, tetanus status, occupation, spine immobilisation is key, ON EXAMINATION - midline and paravertebral cervical spine tenderness, deformity, limb weakness
Ix - examine cervical spine with palpation and movement if patients have GCS of 15, sober and no focal neurology or distracting injuries and no neck pain, CT cervical spine or C-spine x-ray
Rx - if abnormal scans then leave neck immobilised and refer urgently, carry out neuro obs, normal scans require senior review.
What risk factors qualify a CT cervical spine within 1hr
GCS<13
Intubation
Before surgery if definetly getting surgery
High risk injury
How is whiplash managed
S - gradual onset of a painful and stiff neck, few hours/days after injury, tender over neck paravetrebral and midline area
Ix - clinical, X-ray if unsure
Rx - paracetamol and regular NSAIDs, rest for 48hrs then return to normal activities
Give some causes of falls
MI
Postural hypotension
AS
Ataxia
PD
Alcohol excess
Delirium
Trip
Peripheral neuropathy
dysrhytmias
Shock
Sepsis
Stroke/TIA
Seizure
Hypoglycaemia
PE
Hpoxia
How are falls managed
Highly depends on cause.
S - ask about what they were doing before, during and after fall, any witness accounts, chest pain, palpiations, dizziness, confusion, tongue bitting, urination, fever, PMH diabetes, epilepsy, PD, CV disease, D+A sedatives, hypoglycaemic drugs
Ix - routine bloods, drugs chart review, possible CT head (1hr or 8hrs), x-ray of any sore joints
Rx - treat cause and any injuries
What are the features of a falls review
Before visiting - ask nurse to do a full set of obs, postural BP and blood glucose, ECG, get collateral to see if its been witnessed.
S - events leading up to fall, dizziness, palpitations, weakness, aura, during - do they remember everything, did they lose conciousness, after - do they remember getting up, pain anywhere, how long were they on the floor, PMH previous falls, heart issues, DM, PD,D+A - anticoagulants, antihypertensives, antiepileptics, hypoglycaemics, diuretics, nitrates, SH - alcohol, mobility, eat and drinking, ON EXAMINATION - brief CV and neuro exam, look over head for signs of injury, feel c-spine, check for reduced arm and shoulder and leg movement - especially for a fractured NOF, ensure patient is back to full mobility for themselves
Ix - ECG, observations, lying standing BP, 4AT, routine bloods if required, CT head if required, X-ray if fracture.
Rx - treat cause, document findings and inform senior, ask nurses to fill out an incident form.
Review patient in 4hrs if suspected neuro. ask nurses to do hourly neuro observations.
Give some causes of situational syncope
Micturition - vagal tone causes collapse, get them to sit down to urinate
Carotid sensitivity - can be brought on by shaving
Cough - brought on by coughing fits
How is an acutely painful limb managed
Hx - SOCRATES, any associating symptoms, PMH of CV disease, recent surgery that could mean compartment syndrome, painful joint? septic arthritis, skin changes? necrotizing fascitis, sickle cell crisis? drugs and allergies
A - patency
B - RR, sats, listen to chest, percuss, O2 if needed
C - ECG (exclude MI if arm pain), BP, listen to hear, IV access with bloods (FBC, U+E, D-dimer, troponin, LFT, CRP), HR, ABG (acidosis),
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs - pulses, temperature, parasthesia, tenderness, doppler, ABPI, CRT, parasthesia and motor
Call senior
Reassess
Acute ischaemic limb - analgesia and vascular surgeons, analgesia
Compartment syndrome - remove plaster and orthopaedics, analgesia
Septic arthritis - joint aspiration and IV abx with orthopaedics, analgesia
Nectrotizing fasciitis - IV abx and surgeon input, analgesia
Gangrene - IV abx, analgesia and surgical input
How is superficial thrombophelbitis managed
S - gradual onset of tenderness over the vein, red and hard palpable vein, DVT RFs present
Ix - wells score, s-simer and doppler
Rx - elevate, exercise, compression, analgesia, LMWH if DVT suspected
How is muscle pain managed and some possible causes
A - trauma, fibromyalgia, infection, rhabdomyloosis, drugs (statins, ACEI, steroids), polymyalgia rhemuatic, dermatomyositis, SLE, metabolic (low potassium calcium or sodium) thyroid disease, cushings disase, referred joint pain
Ix - routine bloods, CK, ESR, X-ray
Rx - trat cause and consider physio
How is osteomyelitis managed
S - hot, swollen deep seated painful bone, fever, malaise, tender bone
Ix - routine bloods, ESR, x-ray (poor sensitivity in first 10 days), MRI required (GS), bone biopsy/ USS-guided aspiration may be required for abx sensitivity
Rx - high dose antibiotics (6wks), surgical debridement and drainage if abscess
What is dry gangrene and how is it managed
Necrosis without infection
S - well-defiend, painless, shrivelled black/brown area
Ix - clinical
Rx - debridement or amputation, may even wait for it to fall off itself
How is acute limb ischaemia managed
S - unilaterally painful, pulseless, cold limb, parasthesia, paralysis, slow CRT, COMPARE LIMBS
Ix - FBC, ECG (AF is RF), CRP, LFTs, U+Es, doppler will show reduced or absent pulse (may be slushy pulse), ABPI
Rx - call vascular - embolectomy, intra-arterial thrombolysis, bypass or amputation, IV morphine and fluids
How is wet (gas) gangrene managed
S - unwell, painful extremities or wound, fever, systemic shock, bilstering around necrotic site, crepitus (from gas in the tissue)
Ix - routine bloods, CK, blood cultures, clotting, ABG (acidosis), gram stain of wound swab, x-ray (gas patches in soft tissue)
Rx - call senior surgeon for debridement, oxygen, fluids, broad spectrum antibiotics
How is compartment syndrome managed
S - excessive pain post fracture/injury, distal tingling, numbness, weakness, cool peripheries, pain at rest, worse on passive stretching of the muscle, reduced sensation, redness, swelling, slow CRT
Ix - clinical, compartment presssure using a manometer, may need updated bloods including CK
Rx - oxygen, elevate limb with patient lying flat, morphine, IV fluids if dehydrated, remove plaster cast, call orthopods for urgent fasciotomy.
How is peripheral aterial disease managed
S - claudication, hairloss, leg pain at night which is eased by hanging foot out of the bed, cold leg
Ix - FBC, lipid profile, CRP, U+Es, ESR, ABPI with doppler, ECG
Rx - treat vascualr RFs (exercise, better diet, stop smoking), statins, avoid beta bockers, surgical referral for bypass or angioplasty may be needed.
What do the ABPI values suggest
> 1.3 - may be calcified or not PVD
0.8-1.3 - normal
0.5-0.8 - Moderate PVD
<0.5 - critical limb ischaemia
How is lumbar spinal stenosis managed
S - cramp in thigh or legs on walking, worse when walking downhill or standing, associated back pain, pain on straight leg raise or back extension, usually no neuro symptoms
Ix - lumbar spine x-ray, MRI spine
Rx - exercise, NSAIDs, steroid injections, spinal decompression
How is carpal tunnel syndrome managed
S - aching of wrist and forearm, tingling of thumb, index, middle and ring finger, weaker grip
Ix - clinical
Rx - splints, steroid injections, surgical decompression
How is limb swelling managed
S - location, SOCRATES, associated symptoms (fever, reduced ROM, skin changes, weight loss, nausea, vomiting), PMH recent surgery, rheumatoid diseases, DH (CCBs, HRT/COCP and allergies), SH (travel, alcohol and smoking)
Ix - Look, feel, move, x-ray, doppler, routine bloods, CK, lactate, look for ascities or fluid overload elsewhere, CXR + ECHO if cardiac, abdo USS if liver, renal USS if kidney disease
Rx - treat cause
How is lymphoedema managed
S - limb swelling, reduced mobility, infections, pitting or woody if chronic
Ix - USS of lymph nodes
Rx - elevation, compression bandages, massage proximally, abx if infection, diuretics not shown to work
How is a DVT managed
S - unilateral swollen hot limb, painful, reddening of skin, PMH (cancer), D+A (COCP, HRT), SH (recent long haul flight)
Ix - routien bloods, Well’s score, D-dimer, ECG, ABG may be needed if resp symptoms.
Rx - fluids, analgesia, if d-dimer positive or delayed <4hrs then start enoxaparin
How is chronic venous insufficiency managed
S - thrombbing leg pain, relieved by elevating legs, worse on standing, previous DVT or thrombophlebitis, red discoloration, hyperpigmentation of skin
Ix - USS doppler, d-dimer, ABPI
Rx - compression mandages, varicose vein surgery - sclerotherapy or thermotherapy
What antibiotics do you give for a cannula site infection
Co-amoxiclav
What is an important differential for DVTs and why
Baker cyst - found in popliteal fossa but pain and swelling often radiates to calf so need a USS doppler to differentiate them
How is angioedema managed
S - colicky abdo pain, SOB, Dysphagia, watery dirrhoea, itch, well-demarcated swelling, urticaria
Ix - clinical
Rx - ABCDE, senior help IM adrenaline, salbutamol, chlorphenamine, hydrocortisone 200mg, identify cause and stop in future (ACEi), immunology referral
How is joint pain managed
S - SOCRATES, ROM, skin changes, associated symptoms (diarrhoea, STI symptoms, weight loss, trauma, fever, night sweats, SOB, dry eyes and mouth), deformity, crepitus, lymphadenopathy, hepatosplenomegaly
Ix - routine bloods, CK, ESR, Rh factor and ANA, urine dipstick, x-ray, joint aspiration
Treat cause
Give some causes of joint pain
OA
RA
Septic arthiritis
Fracture or ligament injury
Transient synovitis
Osteomyelitis
Enteropathic arthritis
Gout and pseudogout
Polymyalgia rheumatica
Ankylosing spondylitis
Leukaemia
Sickle cell
Haemophilia
How is rheumatoid arthritis managed
S - morning stiffness, malaise, fatigue, mild fever, weight loss, swelling, deformity and redness or small joints
Ix - FBC (anaemia), ESR, Rh F and anti-CCP, x-ray (erosions, cysts, osteopenia, narrow joint space, deformity)
Rx - analgesia, NSAIDs, exercise, physio, IM methyl pred (exacerbation), DMARDs
How is osteoarthritis managed
S - pain worse with activity, stiffness on resting, effusion or joint deformity, reduced range of motion and crepitius
Ix - routine bloods (normal or mildy raised CRP), X-ray (loss of joint space, osteophytes, subacondral cysts and subcondral sclerosis
How is polymyalgia rheumatica managed
S - biateral morning stiffness and pain in proximal muscles lasting >1hr, weight loss, fatigue, malaise, depression, mild fever, normal power but muscle tenderness, ask about STA arteritis symptoms
Ix - raised ESR, CRP, LFTs, CK, STA biopsy if required
Rx - prednisalone, gradually reduced over a number of months
How is septic arthritis managed
S - acute onset painful swollen erytematous joint, essentially no ROM due to pain, fever, hot and tender
Ix - FBC, CRP, ESR, positive blood culture, x-ray, joint aspiration (positive for organsms on culture)
Rx - analgesia, urgent ortho referral and high dose IV abx for 6 weeks, aspiration and wash out likel required.
How is gout managed
S - acute painful joint, possible fever, decreased range of movement, swollen, tender, alcohol and red meat, thiazide diuretics
Ix - routine bloods, x-ray, joint aspiration (negative birefringent needle shaped crystals)
Rx - acute - rest, fluids, reduced thiazide duiretics alcohol and red meat, diclofenac or colchicine, chronic - allopurinol, do not start in acute attacks
How is pseudo-gout managed
S - acute painful joint, possible fever, decreased range of movement, swollen, tender, usually less severe than gout and usually affects small joints compared to gout which affects the knee most commonly
Ix -routine bloods, x-ray, joint aspiration (positive birefringement crystals)
Rx - Rest, NSAIDs (diclofenac), no prophylactic treatment
How is ankylosing spondylitis managed
S - back pain worse at night, morning stiffness>1hr, heel pain, resitricted chest expansion, achilies enthesitis, aortic regurgitation,
Ix - clinical, sacroiliac disease on x-ray pelvis
Rx - exercise, NSAIDs, sulfasalazine, infliximab
How is reactive arthritis managed
S - pain in larger joints, recent diarrhoea or genitourinary infection, dysuria, urethral discharge, acute asymmetrical oligoarthritis with malaise, fatigue and fever, gritty eyes, bilateral conjuctivitis, joint inflammation and urethritis
Ix - FBC, CRP, U+E, x-ray (normal), throat or genital swabs
Rx - treat infection (little effect on reactive arthritis), NSAIDs, chloramphenicol eye drops
How is psoriatic arthritis managed
S - skin changes (psoriatic), varying pattern of joint inflammation, check scalp, nail changes, swollen fingers
Ix - ESR, CRP, FBC, serology negative, X-ray (pencil tip appearance but mild arthritis seen)
Rx - rest , splinting, treat psoriasis, NSAIDs, steroids and biologics if severe
How is SLE managed
S - malaise, fever, weight loss, joint pain, photosensitive malar or discoid rash, oral ulcers, oedema, haematuria, seizures, psychosis, chest pain, abdo pain, diahrrhoea, pallor, recurrent miscarriages, swollen joints, drug induced (isoniazid, methyldopa, hydralazine, diltiazem)
Ix - routine bloods (anaemia, low WCC and platelets), C3 and C4 compliment low, raised ESR ANA positive dsDNA positive, anti-sm, rhf, urinalysis (blood and protein), x-ray pleural effusions and arthritis
Rx - nsaids, hydrocychloroquine, oral steroids for flares, DMARDs, biological therapies
