emergency medicine

Question 1

what are the 2 parts that make up an altered mental state?

Answer 1

level of consciousness (attentiveness)

cognition (mental processes or thoughts)

disorders may be of 1 or both

Question 2

what is a symptom sieve?

Answer 2

broad categories of pathological processes that cause a symptom or disease

e.g. trauma, autoimmune

Question 3

what is the symptom sieve for patients with altered mental state?

Answer 3

Psychiatric

Endocrine/Metabolic

Toxins

Primary Neurological

Infection

Gastro-intestinal

Cardiorespiratory

(PET PIG C)

Question 4

what is the assessment of Bill’s airway (A)?

Answer 4

intermittent verbalisation

no foreign objects in mouth or excessive secretions

no snoring, no stridor

no mouth or tongue swelling

Question 5

what is the assessment of Bill’s breathing (B)?

Answer 5

respiratory rate - 14 breaths/minute

oxygen saturation - initially 90%, 94% after 2l oxygen

no evidence of respiratory distress

mild wheeze

smoker

(abdominal distention could affect respiration, affect diaphragm)

(check compromised/scalene muscles - also assist in breathing, and affect respiration if damaged)

Question 6

what is the assessment of Bill’s circulation (C)?

Answer 6

BP 89/64 mm Hg

heart rate - 110 bpm, regular (high)

heart sounds - normal

12 lead ECG - sinus tachycardia, no ischaemic changes

peripheral capillary refill brisk bilaterally (under 2 secs - liver failure?)

warm peripheries, looks flushed

Question 7

which of Bill’s circulation stats is the most worrying?

Answer 7

low blood pressure (89/64 mmHg)

Question 8

what are the 4 types of shock?

Answer 8

cardiogenic

hypovolemic

obstructive

distributive

Question 9

what are the 3 types of distributive shock?

Answer 9

septic

anaphylactic

neurogenic

Question 10

what is hypovolemic shock?

Answer 10

result of loss of high volume of fluid

heart cannot pump enough blood, can lead to organ failure

Question 11

what is cardiogenic shock?

Answer 11

heart suddenly can’t pump enough blood to meet your body’s needs

often caused by a severe heart attack

peripheries are cold, pulmonary oedema

Question 12

what is obstructive shock?

Answer 12

physical obstruction of vessels

Question 13

what is distributive shock?

Answer 13

due to excessive vasodilation

abnormal distribution of blood flow in the smallest blood vessels results in inadequate supply of blood to the body’s tissues and organs

total peripheral resistance drops and so blood pressure drops

Question 14

what is the assessment of Bill’s disability (D)?

Answer 14

blood glucose - 5.7

temperature - 38.2 degrees

confused (ACVPU - alert, confusion, voice, pain, unresponsive)
GCS E3 V4 M5
(eyes, verbal, motor on scale of 1 to 5, 1 being the lowest)

4 limbs moving normally

PEARL (pupils equal and reactive to light) - 3mm

probably intoxicated

Question 15

what is the assessment of Bill’s exposure (E)?

Answer 15

no rashes

no sites of injection/track marks

no evidence of trauma to limbs or head

no evidence of external bleeding

abdominal examination - abdomen distended, tender in left iliac fossa

Question 16

how is SIRS diagnosed?

Answer 16

2 or more of:

• temperature lower than 36 degrees or higher than 38 degrees
• heart rate over 90bpm
• respiratory rate over 20
• WBC over 12 x 10⁹/L or under 4 x 10⁹L

Question 17

how is sepsis diagnosed? what tests must be done to check?

Answer 17

meets SIRS criteria with evidence of infection

take blood cultures

Question 18

how is severe sepsis diagnosed? what tests must be done to check?

Answer 18

sepsis with evidence of organ dysfunction, hypotension or hypoperfusion

lactate and urine output

Question 19

how is severe sepsis diagnosed?

Answer 19

severe sepsis with hypotension despite adequate fluid resuscitation

Question 20

what are the 6 steps to treat suspected sepsis?

Answer 20

give oxygen (keep sats above 94%)

take blood cultures

give IV antibiotics

give fluid challenge (give fluid and check effect on blood pressure)

measure lactate (kidneys - check perfusion)

measure urine output

Question 21

what are the 2 different impressions given of Bill?

Answer 21

sepsis

altered mental state due to (sepsis), alcohol, delirium, drugs and intercranial pathology

Question 22

what tests have to be done after the initial impressions of Bill?

Answer 22

sepsis management

investigate source of sepsis

CT scan to rule out intracranial pathology

toxicology screen (rule out alcohol etc.)

blood culture

biochemistry: CRP, creatinine, urea, Na, K, ALT, ALP, GGT, bilirubin, amylase, lactate
haematology: Hb, WCC, Neut, PLT

Question 23

which biochemistry results support a diagnosis of sepsis?

Answer 23

high CRP - marker of inflammation, link to infection

high creatinine, urea - indicative of kidney and renal problems, maybe hypoperfusion

high WBC, Neut - inflammation

high lactate - marker for sepsis

(high GGT and ethanol probably due to alcohol, nothing to do with sepsis)

(all negative on toxicology, so not drug effect)

Question 24

what are the steps to take after the toxicology screen?

Answer 24

analgesia for pain in abdomen

CT abdomen and pelvis

continue IV fluids, antibiotics

Question 25

what does a NEWS score of 3 indicate?

Answer 25

no need for escalation

Question 26

what are the 3 most likely causes of Bill's confusion from the symptom sieve?

Answer 26

infection gastro-intestinal toxins

Question 27

since the pain is localised in the left iliac fossa, what organ (s) may be causing Bill's pain?

Answer 27

sigmoid and descending colon could also be kidney or bladder (if female could also be uterus, womb, ovaries - do a pregnancy test)

Question 28

what condition is Bill likely to have?

Answer 28

probably not appendicitis due to age, appendix is generally in right fossa acute kidney injury - would have showed in other tests colorectal adenocarcinoma - can be seen on CT sigmoid diverticulitis most likely (multiple diverticulae are seen, sigmoid colon displays wall thickening - peri colic fat stranding is also sign of diverticulitis)

Question 29

what is a diverticulum?

Answer 29

small, bulging pouch that can form in the lining of digestive system, more common with increasing age use ultrasound to detect

Question 30

what is the difference between diverticulitis and diverticulosis?

Answer 30

diverticulitis: outpouching with infection/inflammation faeces gets trapped and stagnates in a diverticulum, causes overgrowth of gut bacteria diverticulosis: outpouching without inflammation

Question 31

what does diverticular disease cause?

Answer 31

diverticula cause intermittent abdominal (usually left) cramp-like pain, bloating (without swelling (inflammation) or infection) get ease from pain and bloating by passing stools some may develop diarrhoea or constipation, and some people pass mucus with their stools - unclear how diverticula causes this (symptoms can be similar to IBS - however, IBS usually affects younger adults) diagnosis: confirm presence of diverticula, rule out other causes of symptoms. symptoms of diverticular disease, especially if they start in an older person, can also be similar to those of early bowel cancer so tell a doctor if you develop these symptoms, as some tests may need to be arranged (e.g. colonoscopy) diverticula may occasionally bleed abruptly and painlessly due to a burst blood vessel that sometimes occurs in the wall of a diverticulum- go see a doctor (in case of bowel cancer etc.)

Question 32

what is in the right upper quadrant of the abdominopelvic region?

Answer 32

right liver gallbladder right kidney small part of stomach duodenum head or pancreas portions of ascending and transverse colon parts of small intestine

Question 33

what is pain in the right upper quadrant associated with?

Answer 33

infection/inflammation in gallbladder and liver peptic ulcers

Question 34

what is in the left upper quadrant of the abdominopelvic region?

Answer 34

left portion of the liver part of the stomach pancreas left kidney spleen portions of the transverse and descending colon parts of the small intestine

Question 35

what is pain in the left upper quadrant associated with?

Answer 35

malrotation of the intestine and colon

Question 36

what is in the right lower quadrant of the abdominopelvic region?

Answer 36

cecum appendix part of the small intestines right half of the female reproductive system right ureter

Question 37

what is pain in the right lower quadrant associated with?

Answer 37

appendicitis

Question 38

what is in the left lower quadrant of the abdominopelvic region?

Answer 38

majority of the small intestine some of the large intestine left half of the female reproductive system left ureter

Question 39

what is pain in the left lower quadrant associated with?

Answer 39

colitis (inflammation of the large intestine) pelvic inflammatory disease ovarian cysts

Question 40

what does the right hypochondriac region contain?

Answer 40

right portion of the liver gallbladder right kidney parts of the small intestine

Question 41

what does the left hypochondriac region contain?

Answer 41

part of the spleen left kidney part of the stomach pancreas parts of the colon

Question 42

what does the epigastric region contain?

Answer 42

majority of the stomach part of the liver part of the pancreas part of the duodenum part of the spleen adrenal glands

Question 43

what does the right lumbar region contain?

Answer 43

gallbladder left kidney part of the liver ascending colon

Question 44

what does the left lumbar region contain?

Answer 44

descending colon left kidney part of the spleen

Question 45

what does the umbilical region contain?

Answer 45

umbilicus (navel) many parts of the small intestine part of the duodenum, the jejunum, and illeum transverse colon bottom portions of both the left and right kidney

Question 46

what does the right iliac/inguinal region contain?

Answer 46

appendix cecum right iliac fossa

Question 47

what does pain in the right iliac region indicate?

Answer 47

appendicitis

Question 48

what does the left iliac/inguinal region contain?

Answer 48

descending colon sigmoid colon left iliac fossa

Question 49

what does the hypogastric region contain?

Answer 49

bladder part of the sigmoid colon anus most of reproductive system (uterus and ovaries in females, prostate in males)

Question 50

why do diverticula develop?

Answer 50

lack of fibre gut moves stools along by muscular wall movements stools tend to be drier, smaller, and more difficult to move along if you don't eat much fibre - muscles have to work harder if there is too little fibre in your gut high pressure may develop in parts of your gut when it squeezes hard stools increased pressure may push the inner lining of a small area of your gut through the muscle wall to form a small diverticulum

Question 51

what are the symptoms of diverticulitis?

Answer 51

constant pain in the abdomen (commonly in the lower left side of the abdomen, but can occur in any part of the abdomen - in people of Asian origin, it sometimes occurs on the right side) high temperature (fever) constipation or diarrhoea some blood mixed with your stools nausea or vomiting

Question 52

what are some complications caused by diverticulitis?

Answer 52

obstruction of the colon abscess may form in the abdomen channel (fistula) that may form to other organs such as the bladder perforation in the wall of the bowel that can lead to infection inside the abdomen (peritonitis)

Question 53

how is diverticulosis treated?

Answer 53

high fibre diet (about 18g per day) with high fibre, lots of fluid (at least 2l per day) paracetamol to ease pain (NSAIDs and opioids should be avoided as they can cause perforation) antispasmodics such as mebeverine if you have persistent abdominal spasms

Question 54

how is diverticulitis treated?

Answer 54

if generally unwell: antibiotics, high fibre diet, maybe strong painkillers if symptoms are severe/prolonged: hospitalised - IV drip, antibiotics if any complications, surgery is needed (e.g. to drain abscess, remove infected colon)