case by case Helen Emery

In this podcast we discuss the case of:
44 year old female who presented at 4am in the morning with an acutely red and painful right eye. She had thought that the eye had started to feel a bit irritated that evening on returning from work and it had steadily worsened from there. She came to the ED as she couldn’t get off to sleep on account of the discomfort and felt as though there was something in the eye. She described some increased tearing but no discharge and mild blurred vision. No flashers or floaters. There was an associated mild headache, with mild photophobia. She denied trauma. She had been well recently.
Contact lens wearer, often works very long hours and does not always take them out to sleep and perhaps does not change them as suggested.
Past Medical History: Nil
Drug History: Nil
Social History: Lawyer, independent, Lives alone
Examination
Looked uncomfortable
Visual acuity (corrected) LEFT 6/6, RIGHT 6/9
Full range of eye movements
Visual Fields: normal
Externally: Normal
Lids and Lashes: No erythema, no collection, no subtarsal foreign body
Anterior Chamber: No hyphema (pooling of blood between in the anterior chamber (space between the cornea and iris), no hypopion (inflammatory cells in anterior chamber), no cells/flares
Conjunctiva: Mildly injected generally, no focussed redness suggesting iritis or episcleritis
Pupil: Round and symmetrical, equal and reactive to light
Iris: Normal
Cornea: ? more opaque than LEFT although red reflex preserved, some fluorescein uptake centrally
Have a listen to the podcast for the differential diagnoses and to find out what happened.
Music by BenSound. 

In this podcast we discuss the case of:
34 year male brought in by ambulance feeling unwell. He had had a recent history (of about 48hrs) suggestive of upper respiratory tract infection (URTI) - runny nose, productive cough, sore throat etc. However, in the last 12 hours or so she had started to feel much more unwell. He felt more washed out and lightheaded, developed nausea and had vomited once or twice. He also felt that there was a slight increase in the cough.
He complained of a mild headache. He denied urinary symptoms although said the urine was darker than normal. There was no chest or abdominal pain or loose stool.He denied rashes, photophobia or neck stiffness.
Past Medical History:   Well controlled Crohn’s disease - didn’t feel like a flare
Drug History:      Budesonide 3mg TDS,  NKDA
Social History:       Independent. Lives with partner. Accountant. A non-smoker.
Examination
He looked unwell, was mildly shocked - BP 89/53 and HR 118. Currently afebrile.
A – Patent
B – Talking in full sentences. Sp02 100% (15L NRBM). RR 23. A few crackles LEFT base. Calves SNT. No chest wall tenderness.
C – HR 118. BP 89/53. Heart sounds normal. Warm peripheries.
D – GCS 15/15. No facial weakness. No limb weakness. Making co-ordinated movements. No photophobia. Freely moving neck. Kernig’s neg.
E – Temperature 38.1. Abdomen - Not distended. Soft. Mild non-tenderness. No guarding. Bowel sounds normal. No rashes.
ENT - Mildly red throat. Normal voice. Mildly red ears. No lymphadenopathy
Have a listen to the podcast for the differential diagnoses and to find out what happened.
Music by BenSound. 

In this podcast we discuss the case of:
A 28 year old female presented on a weekend after feeling unwell for about 5 days, she thought she had a cold/flu but it wasn’t improving so she came to the ED. She complained of very non-specific symptoms: mild headache, lethargy, felt a bit feverish, mild joint stiffness/pain. There were no coryzal symptoms - runny nose, cough, sore throat or sneezing.
She had not felt like eating and drinking but was able to ‘force’ herself and was able to keep food/fluids down. She had been passing urine normally with no symptoms. There was no nausea or vomiting. There was no neck pain or headache or photophobia.
Past Medical History : Normally fit and well
Drug History: Nil regularly, NKDA.
Social History: Independent, lived alone, she worked in IT and she was in the Army Reserve. No recent foreign travel.
Examination
She looked ok. Had normal vital signs, not tachycardic, normal BP, temperature of 37.8.
ENT - normal, no lymphadenopathy.
Respiratory  - chest clear, normal RR, Spo2 98%.
Abdominal  - Soft, non-tender, no organomagely, bowel sounds normal.
CNS - normal. Normal Gait. Normal neck movements, no photophobia. Kernig’s negative.
She reported no rashes but did mention that she had a red patch on her LEFT upper calf.
Skin - approx. 6cm x 6cm red ‘bullseye’ patch popliteal fossa

Further questioning she had been on exercise with the Army 10days previously.
 
Have a listen to the podcast for the differential diagnoses and to find out what happened.
Music by BenSound. 

In this podcast we discuss the case of:
66 year old gentleman was out having dinner with his family. He describes the pub as very hot, half way through eating his main course, he became very hot and a sweaty and then everything went blank. When he woke, his family were all gathered round him, fanning him. He had not bitten his oral mucosa and had not been incontinent. He felt a bit out of sorts, but knew where he was. An ambulance was called and he was brought to hospital.
His wife attended hospital with him, and reports that half way through the meal, he became very quiet and visibly sweaty and fell unconscious for approximately one minute. She reports he was breathing throughout. When he came round, he was a little ‘dazed’ but quickly recovered. The family were a bit concerned because when he was unconscious he had some twitching of his arms and legs.
The patient reported no preceding chest pain, palpitations, shortness of breath, he felt suddenly lightheaded just before he collapsed. No head injury. He has never lost consciousness before.
Past medical history: Hypertension, osteoarthritis, hiatus hernia
Drug history: Ramipril, amlodipine, paracetamol, lansoprazole, NKDA
Social History:, Retired caretaker, lives with wife, independent, never smoked, alcohol 2 pints three days a week
Examination
Appears well
Talking in full sentences, not confused
RR 16, SpO2 98% on air, chest clear
HR 86 reg, lying BP 133/59, standing 136/62, HS I+II +0
ECG – normal sinus rhythm
GCS 15/15
Cranial nerves in tact
Normal neuro exam
 
Have a listen to the podcast for the differential diagnoses and to find out what happened.
Music by BenSound. 

In this podcast we discuss the case of 
19 year old female with a history of abdominal pain. She had noticed the pain during a morning lecture and it had initially been mild and generalised. Early associated features included nausea, malaise and she had had two episodes of loose stool. She was a new student and had been living that lifestyle so she thought that it was probably due to alcohol.
However in the last couple of hours, the pain had significantly worsened. She described it as constant and sharp. She had vomited and didn’t feel like eating or drinking. She had no further diarrhoea, was passing urine although concentrated. She was advised to come to hospital by the 111 service. There was no PV bleeding, no malena or haeamtemasis and no urinary symptoms. Her last menstrual period was 6 weeks ago and normal, she has a very irregular cycle that can vary from 3-8 weeks.
She had well controlled asthma using salbutamol and beclomethasone, no other medications and no drug allergies. Interestingly she had had a couple of previous episodes of right lower abdominal pain before - although not as bad as this, this was when she was diagnosed and treated for pelvic inflammatory disease 18 months ago. She was a non-smoker, denied illicit drugs, being a new student she had been drinking more alcohol than usual.

Exam
She still looked uncomfortable - scoring pain 5/10. She was alert and orientated. Her vital signs were stable but she had a HR of 104, BP 104/62, RR 16, Sp02 100% and a temperature of 37.8*. The abdomen was soft but was mildly tender in the epigastrium and tender with some guarding in the right lower quadrant. Rovsings positive. Murphy's negative. Rebound tenderness. Bowel sounds slightly increased.
Have a listen to the podcast for the differential diagnoses and to find out what happened.
Music by BenSound. 

In this podcast we chat through the case of a 23 year old female patient who walked into the Emergency Department complaining of a severe headache. She had no history of headaches. The pain was 9/10 and she couldn’t localise it. She said she’d had a niggling headache since lunchtime time but it had worsened throughout the day. Described as a throbbing pain, which didn’t radiate down to her neck. At home she’d tried paracetamol which eased it very slightly to an 8/10. Not worsening on bending or coughing. She felt more comfortable with the light off and just wanted to go to sleep. No vomiting.
She stated her vision was fine at the time of review, but for about half an hour before the headache came on she reports not being able to see around the edge of both eyes. She denied any flashing lights or zig-zag lines, no speech disturbance and no weakness of her arms or legs.
She had no past medical history, had a contraceptive coil fitted but on no medications. She lived with her partner, worked in retail, non-smoker, no drugs, occasional alcohol binge.
Nothing to find on examination.
Have a listen to the podcast for the differential diagnoses and to find out what happened.
Music by BenSound.