a diligent driver…

The Case.

A 25 year old registered nurse presents to her GP with a 6 day history of abnormal vision, which she noticed whilst checking her blind-spot when driving. This has been accompanied by painful extraocular movements & the sensation that her right eyelid was drooping. She has had a recent viral URTI & has been quite stressed at work with a pending presentation and upcoming exams….

She has been referred to your ED today (by the Ophthalmologist) with the following visual field examination

LeftEye    RightEye

** hence the "droopy eyelid" **

On examination, her pupils are equal & reactive directly, but there is a positive Marcus-Gunn reflex on the right side. VA 6/5 on (L) & 6/18 on (R). Normal EOM, but reports pain in the right eye with lateral gaze (“like a tight cord pulling”).

She is holding a letter from the Ophthalmologist which states, “please start treatment!”

What’s the diagnosis ?
What are we treating & why ??

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The Case.

A 38 year old male presents to your ED with left sided chest heaviness which radiates to his left shoulder & down the arm. He has associated dyspnoea, nausea & vomiting. He looks unwell.

He underwent a CT-Coronary Angiogram 4 months earlier showing a Calcium-Score of 450 !! (‘Extensive plaque burden’. 8x increase in Framingham predicted risk). However, a Sestamibi study performed at the same time showed no evidence of inducible ischaemia.

This is his ECG…

38yo ECG01

What’s your interpretation ?
Is it significant ??
Where do you go from here ???

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hard & soft…

The Case.

A 22 year old male is retrieved to ED after a nasty workplace accident where he was pinned between a truck and wayward forklift. He had sustained injuries to his head/face, upper thorax and perineum, however our most significant concern was regarding his right lower limb. He had a displaced, angulated compound femur fracture that required sedation and pre-hospital reduction. There were reports of significant bleeding at the scene.

No immediate interventions were required following his primary survey, but his right limb revealed a nasty tissue defect and open fracture (now splinted). There was no active blood loss, but his leg distal to the injury was pale and cold with no appreciable dorsalis pedis or posterior tibial pulses.

Here are his initial xrays….

Femur Xray Femur Xray01

As there was concerns regarding intraabdominal and pelvic injuries; he was taken to radiology for CT, including angiography of his lower limbs….

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a pulmonary pummelling…

The Case.

This patient has been in your ED for over 24 hours waiting for a CCU bed. He presented with vomiting and syncope, but acquired left sided rib fractures during his collapse. He has been comfortable for most of the day on nasal-prong oxygen and a morphine PCA.

You are asked to see him as he has sudden worsening of his left-sided chest pain. He has become clammy and hypoxic.

This is what you see….

What’s going on ?
What are you going to do now ??

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an obscure acidosis…

The Case.

64 year old male attends your ED with a complaint for 3 months of progressive weakness, however over the past 7 days he has had multiples falls secondary to his ‘legs just completely giving way’.  You note on the hospital records that he has a history of alcoholism (150-250 grams per day). After a long & drawn out discussion (think, blood from a stone) in an attempt to elaborate his history, you gain the knowledge that …

  1. he has had some chronic worsening, low back pain
  2. he has not eaten a proper meal for over a week (and no alcohol in that time either)
  3. he has lost a ‘decent amount of weight’, but cannot objectify it any further.

He has no known past medical history & takes no regular medications.

He looks crook. Pale, diaphoretic and clammy. Tachycardic (@120/min) and hypertensive (165/110 mmHg). He is afebrile however. No murmurs, chest clear. Tender hepatomegaly. No midline back pain. Normal power, sensation and reflexes to both legs (with good peripheral pulses).

Here is his venous blood gas and accompanying chemistry….


What are your thoughts ?
Differential diagnoses ??
What are you going to do next ???

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headache for all…

The Case.

A 28 year old female presents to your ED at 2am. She left the hospital 12 hours earlier with her newborn first child who is now 2 and half days old. Her main complaint is that of profound lethargy, fatigue, severe worsening bifrontal headache and breathlessness.

She is normally fit and well, takes no regular medications & has no significant past medical history. Her pregnancy was uneventful, but her delivery (at 39 weeks) was slightly hair-raising with foetal distress & decelerations due to an obstructive labour (requiring a ventouse).

She looks lethargic and is laying quietly in bed, but is speaking in full sentences. Her observations are within normal limits, but her BP catches your eye at 154/89. Her cardiorespiratory exam is unremarkable (specifically, her chest is clear, there are no murmurs & I cannot see a JVP). Her belly is soft with a palpable uterus, midway between  umbilicus & pubic symphysis. She has no peripheral oedema. Her GCS is 15 with reactive pupils and normal cranial nerves. She has impressively brisk reflexes (you don’t need your tendon hammer) and her power/tone/sensation appear symmetrical & normal.

Her bloods are completely normal! (FBC, LFTs, PLTs, even the CRP) !!

Now what ??

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a poison puzzler…

23 year old female is bought to ED by her family after an intentional overdose of ~ 100 ‘diet tablets’ which she ingested 1.5-2 hours earlier.

She is agitated, anxious, tremulous and profoundly diaphoretic.
P 170. BP 123/70. Sats 100%. RR 32. Temp 36.8*C.
Patent airway. Chest clear. Soft, non-tender abdomen.
Pupils 4mm (equal & reactive).
Normal tone & power in all 4 limbs.
5-6 beats of inducible clonus at the ankles.

BSL 13.1
ECG. Sinus tachycardia @ 170/min (confirmed by increasing paper-speed to 50mm/sec).


What do you think she took ?

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