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Lactation Ketoacidosis

I go on about how important it is to be able to interpret blood gases, with our junior doctors and Fellowship Candidates. It can really change your diagnostic capabilities in the emergency department. Here is an interesting case, where gases solve the problem. A 30 yo woman is transferred to your emergency department. She has…

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Inferior infarct: what else to look for

In this video, Dr Sam Bendall presents one of many cases at our ECG workshop. This is now in our CARDIAC COURSE. This case involves the patient with inferior infarction and what else to look for, including posterior infarction and right ventricular infarction with a reminder to think of dissection. The management of these patients is…

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Ventricular tachycardia and methadone

Here’s an interesting cardiac case we had the other day.

A 42 year old male with a past history of IVDU and alcohol abuse and brain injury, presents with what looks like withdrawal. Current medications included methadone and earlier on the same day, he was commenced on naltraxone.

Initially he is found to be becoming progressively more agitated and having brief episodes of depressed conscious state, with improvement between. He is ‘jittery’ with myoclonic movements in the bed. On vitals, he is found to be afebrile with a fluctuating Glascow Coma Score, bradycardic, and to have a systolic blood pressure of 80mmHg, and so he is taken to a resuscitation cubicle.

Is he in withdrawal?
Is he seizing?

As I enter the resus cubicle to find out why the patient is there, I notice a wide complex tachycardia at a rate of about 230bpm. He is still moving. It is self limited after a few seconds. Then a further episode.

In between episodes we do this ECG:[…]

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How good are we at predicting ischaemic chest pain?

Here’s a case I had recently:

62 year old male presents to the Emergency Department with what he calls a flare-up of his congestive cardiac failure. He states he is short of breath. He is a frequent presenter to the department with this complaint. He has not taken his frusemide for the past 48hours.

He states that he feels very tired.

His examination is as follows:

He is a well looking man with normal vitals

Heart sounds dual, no murmur. normal JVP, bilateral pitting oedema to mid calves.

Chest clear

Abdomen soft

His ECG and CXR are normal

Bloods including a troponin are normal.

I’m unsure of the diagnosis, but given he hasn’t taken his frusemide, I treat him with that.

I am going to discharge him, however it is late at night and he lives alone, so we decide to keep him in the department overnight.

In the morning, he looks well and feels better, but still lethargic, ECG is unchanged, but for some reason someone does a follow-up troponin and it is 4.

He is diagnosed with a NSTEMI and sent to cardiology.

So the question I posed was, “How good are we at diagnosing cardiac chest pain?” and “Are there some signs or symptoms such as shortness of breath that are more important than we may initially think they are?”

Pope et al(NEJM 2000;343:1167-1170) looked at the rate of missed diagnoses of cardiac ischaemia in the emergency department.

This was a study of some 10689 patients and the conclusion was that there was a subgroup of patients more likely not to be admitted, who had ischaemia or infarction.

Those more likely to not be admitted were: […]

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Propranolol overdose

This  case study on beta blocker overdose was presented by one of our registrars, at Grand Rounds. It was an interesting case and one we thought you might enjoy. A 53 year old male is brought to the Emergency Department by ambulance: At 2045 he had taken an overdose of his beta blocker medication. The…

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The septic baby

Case Study: Paediatrics—————————————————————–A 5 month old male baby was brought into the Emergency Department by his mother. He is lethargic and limp with occasional aggravated-type crying. The conscious state is alternating between being asleep and agitated crying. He was not quite himself yesterday according to the family.  Today he went off food three hours ago, quite…

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Vertigo part 2 – video of Head Thrust test

I recently spoke about the head thrust test, to differentiate peripheral from central causes of vertigo. Here is a video demonstrating it. Remember that the vestibulo-occular reflex is affected on the side opposite to the quick phase of the nystagmus.

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The glue sniffer’s mother – a case study

Some people have asked me to present an old case I put up at the “Airway, CPR and Trauma” workshop. This is a case I saw as a registrar, simple and effective for teaching. A 56 year old woman presents after midnight to the ED. She says that she is having an anxiety attack, brought on…

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Vertigo and nystagmus

A 65 year old man presents to the emergency department with a sudden onset of ‘dizziness’. He feels more dizzy on any head movement as well as on sitting up. He is finding it difficult to walk around as his balance is affected. This is a common presentation in emergency departments and our main role…

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