AKT – Emergency medicine

James Thornton, aged 64, presents to the emergency department with sudden onset severe central chest pain radiating to his back while gardening. The pain started 30 minutes ago and is described as tearing in nature. He has a history of poorly controlled hypertension and hyperlipidaemia. He appears pale and diaphoretic.

On examination: BP 190/110 in the right arm and 160/95 in the left arm. Pulse 92/min, RR 24/min, O2 sat 97% RA. Cardiovascular and respiratory exams are otherwise unremarkable.

ECG shows sinus rhythm with non-specific ST changes. Chest X-ray reveals a widened mediastinum.

What is the most appropriate next step in management?

Sophia Nguyen, aged 2, is brought to the ED by her parents after ingesting an unknown number of her grandmother’s iron tablets approximately 1 hour ago. She has vomited twice and appears lethargic.

Medications at home include ferrous sulfate, perindopril, and aspirin. The iron tablets were in a non-childproof container.

On examination: HR 130/min, BP 90/60 mmHg, RR 28/min, T 37.5°C. Her abdomen is soft and non-tender, but she is drowsy.

What is the most appropriate immediate management?

Michael Anderson, aged 38, presents with sudden onset severe headache described as the worst in his life. The headache began abruptly while he was lifting weights at the gym. He has vomited twice and is photophobic.

There is no history of trauma. He is alert and oriented but in distress due to pain.

Neurological exam is normal. BP 160/100, HR 88/min. CT brain is performed and reported as normal.

What is the next best step in management?

Linda Rawiri, aged 26, is brought to the ED after collapsing at a music festival. Bystanders report she was found agitated and confused before the collapse. She has a history of depression but is otherwise healthy.

On examination: T 39.6°C, HR 140/min, BP 160/100, RR 28/min. She is confused, with dilated pupils, dry mucous membranes and hyperreflexia. No clonus.

She is wearing a festival wristband. Friends say she may have taken ‘party pills’.

What is the most likely diagnosis?

Thomas Kelly, aged 72, presents with sudden onset of painless loss of vision in his right eye. He describes it as a curtain falling over his vision. He has a history of hypertension and atrial fibrillation.

On examination, visual acuity is reduced to light perception only in the right eye. Fundoscopy reveals a pale retina with a cherry red spot.

What is the most likely diagnosis?

Jessica Farrow, aged 30, presents to the ED following a motorbike collision. She was wearing a helmet but was thrown 10 metres and landed on her side. She complains of left chest pain and shortness of breath.

On examination: T 36.8°C, HR 112/min, BP 100/70 mmHg, RR 28/min, O2 sat 91% RA. Decreased breath sounds on the left with hyperresonance to percussion.

What is the most appropriate immediate management?

Bradley Morris, aged 55, presents with vomiting bright red blood. He has a history of heavy alcohol use and previously diagnosed cirrhosis. He is pale and diaphoretic on arrival.

On examination: HR 122/min, BP 88/60 mmHg, RR 24/min. Abdomen is distended with shifting dullness. Capillary refill is delayed.

What is the most appropriate initial management step?

Emily Watson, aged 19, is brought in by friends after having a seizure at a party. They report she took ‘some pills’ and collapsed shortly after. She has no known past medical history.

On examination: T 40.1°C, HR 140/min, BP 150/90 mmHg, RR 26/min. She is agitated and has bilateral lower limb clonus.

What is the most appropriate next step in management?

George Phillips, aged 67, presents with sudden onset left-sided weakness and slurred speech that began 2 hours ago while shopping. His symptoms have partially improved on arrival to the ED.

On examination: he has mild left facial droop and reduced strength (4/5) in left arm and leg. CT brain shows no haemorrhage.

What is the most appropriate next step in management?

Nathan Rangi, aged 24, presents after being found on the street disoriented and hypothermic. He is homeless and was last seen 12 hours ago. The weather has been cold and wet.

On examination: T 32.0°C, HR 58/min, BP 95/60 mmHg. He is bradycardic, confused, and shivering. ECG shows Osborn (J) waves.

What is the most appropriate next step in management?

Margaret Healy, aged 80, is brought in by her son after an unwitnessed fall at home. She is on warfarin for atrial fibrillation. On arrival, she is alert but confused to time and place. There is a scalp haematoma on the left parietal region.

On examination: BP 145/85 mmHg, HR 90/min, GCS 14. Pupils equal and reactive. No focal neurological deficits.

What is the most appropriate next investigation?

Chris Mathews, aged 45, presents with sudden shortness of breath and pleuritic chest pain. He returned from a long-haul flight from London 2 days ago. He has no significant past history.

On examination: HR 106/min, BP 124/80 mmHg, RR 24/min, O2 sat 93% on RA. D-dimer is elevated. ECG shows sinus tachycardia.

What is the most appropriate next investigation?

Rachael King, aged 27, presents to the ED after being found unconscious in her bathroom. There is an empty packet of paracetamol 500 mg x 40 tablets nearby. She is now alert but nauseated.

On examination: T 36.5°C, HR 88/min, BP 110/65 mmHg. No abdominal tenderness. Time since ingestion is estimated to be 4 hours.

What is the most appropriate management step?

Angela Dawson, aged 33, presents with sudden onset left lower quadrant pain, dizziness, and vaginal spotting. She is unsure if she could be pregnant. Her last menstrual period was 6 weeks ago.

On examination: HR 110/min, BP 92/65 mmHg. Abdomen is tender in LLQ with mild guarding. Urine β-hCG is positive.

What is the most likely diagnosis?

Samuel Kerr, aged 48, presents with crushing central chest pain radiating to his jaw and left arm. The pain began 30 minutes ago while mowing the lawn. He is diaphoretic and nauseated.

On examination: BP 130/85 mmHg, HR 100/min. ECG shows ST elevation in leads II, III, and aVF.

What is the most appropriate next step in management?

Adam Johnston, aged 58, presents with acute onset epigastric pain radiating to the back. He has a history of alcohol use disorder and has been binge drinking over the past week.

On examination: HR 110/min, BP 102/68 mmHg, RR 22/min, T 38.0°C. Abdomen is tender in the epigastrium without guarding. Serum lipase is elevated to 680 U/L.

What is the most appropriate next step in management?

Peter Holland, aged 22, is brought in following a suspected opioid overdose. He is found with pinpoint pupils, shallow breathing, and is unresponsive. Friends say he may have used heroin.

On examination: HR 52/min, RR 6/min, BP 100/60 mmHg, O2 sat 85% on RA. GCS is 6.

What is the most appropriate immediate management?

Deborah Munro, aged 34, presents with right lower quadrant abdominal pain for the past 12 hours. She has anorexia and nausea but no vomiting. Her last menstrual period was 2 weeks ago.

On examination: T 37.8°C, HR 100/min, tenderness and rebound in right iliac fossa. Urine β-hCG is negative.

What is the most likely diagnosis?

Aliyah Khan, aged 3, is brought in by her parents due to fever, drooling, and difficulty breathing. She is sitting upright and leaning forward, refusing to lie down. She has stridor at rest and is febrile to 39.5°C.

On examination, she appears toxic and anxious. No recent vaccinations. Oxygen saturation is 96% on room air.

What is the most appropriate next step?

Henry Wallace, aged 71, presents with increasing dyspnoea and leg swelling over the past 5 days. He has orthopnoea and a past history of ischaemic heart disease and hypertension.

On examination: HR 98/min, BP 140/85 mmHg, O2 sat 93% RA. JVP elevated, bilateral basal crackles, and bilateral pitting oedema to the knees.

What is the most appropriate initial treatment?

Katie Williams, aged 21, presents to ED following a collapse while running a half marathon. Bystanders report she became confused and then collapsed. It is a hot summer day.

On examination: T 40.5°C, HR 135/min, BP 95/60 mmHg, RR 28/min. She is confused and tachypnoeic. No rash or signs of infection are noted. Blood glucose is normal.

What is the most appropriate next step in management?

Luke Tran, aged 45, presents with sudden left-sided chest pain and shortness of breath after vigorous coughing. He is a smoker with a history of emphysema. No trauma.

On examination: HR 102/min, BP 135/80 mmHg, RR 22/min, O2 sat 95% RA. Decreased breath sounds on the left side. CXR reveals a left-sided pneumothorax.

What is the most appropriate next step?

Sandra Foley, aged 36, presents with 4 days of worsening fever, headache and photophobia. She has just returned from a trip to Thailand. She is febrile at 39.2°C, and there is a faint maculopapular rash on her trunk.

On examination: HR 92/min, BP 110/70 mmHg, RR 18/min. No neck stiffness or focal neurology. She is alert and oriented.

What is the most appropriate investigation to confirm the suspected diagnosis?

Eric Dawson, aged 62, presents with a painful, swollen left calf. He returned from a 14-hour flight two days ago. No trauma. He is mildly breathless.

On examination: Calf is warm, red and tender. D-dimer is elevated. Wells score is 3.

What is the most appropriate next investigation?

Chloe Nash, aged 18, presents with nausea, confusion, and tremors. She has been drinking heavily for several days and has now stopped abruptly. She last consumed alcohol 24 hours ago.

On examination: HR 120/min, BP 140/88 mmHg, RR 20/min. She is diaphoretic and restless. No focal neurological signs.

What is the most appropriate initial management?

Leon Harris, aged 74, presents to ED with sudden severe abdominal pain radiating to the back. He has a history of hypertension and is a current smoker. He is pale and clammy on arrival.

On examination: HR 120/min, BP 85/60 mmHg, RR 26/min. Abdomen is tender and pulsatile mass is palpated.

What is the most appropriate next step?

Olivia Kerr, aged 6, is brought in with barking cough, hoarseness, and inspiratory stridor. Symptoms started last night and worsened overnight. She is alert and afebrile.

On examination: HR 100/min, RR 24/min, O2 sat 98% RA. Mild intercostal recession. No drooling.

What is the most appropriate management?

Jackie Thomas, aged 52, presents with acute vertigo, nausea and vomiting. She reports feeling like the room is spinning and it worsens when she turns her head. No hearing loss or tinnitus.

On examination: Positive Dix-Hallpike test. No focal neurological signs.

What is the most likely diagnosis?

Benjamin Yu, aged 31, presents after being stung by a bee. Within 10 minutes he developed generalised urticaria, dyspnoea, and dizziness. He has no known medical conditions.

On arrival: HR 130/min, BP 90/60 mmHg, RR 28/min, O2 sat 93% RA. Wheeze on auscultation.

What is the most appropriate immediate management?

Natalie Price, aged 68, presents with acute confusion, tremor and visual hallucinations 3 days after stopping alcohol abruptly. Her past history includes hypertension and alcohol dependence.

On examination: HR 115/min, BP 150/90 mmHg, RR 20/min. She is agitated and disoriented to time and place.

What is the most appropriate next step in management?

Isla Bennett, aged 25, presents after a fall from a horse at speed. She landed on her outstretched hand and now has severe right wrist pain and swelling. She is unable to move her fingers comfortably.

On examination: swelling and tenderness over distal radius, reduced range of motion. No open wounds. Distal pulses and capillary refill intact.

X-ray confirms a displaced distal radius fracture.

What is the most appropriate next step in management?

Hayden Collins, aged 60, presents to ED with sudden severe tearing chest pain radiating to the back. He is hypertensive and known to be non-compliant with medications.

On examination: BP 190/100 right arm, 160/90 left arm. HR 96/min. ECG is normal. CXR shows widened mediastinum.

What is the most appropriate initial pharmacologic management?

Claire Simmons, aged 32, presents with lower abdominal pain and fever. She reports vaginal discharge and pain with intercourse. No recent travel or surgical history.

On examination: T 38.3°C, HR 104/min, abdominal and cervical motion tenderness.

What is the most likely diagnosis?

Jaxon Lee, aged 19, presents after a skateboarding accident. He has pain and deformity of the right ankle, unable to bear weight.

On examination: obvious posterior displacement of foot relative to tibia, intact skin, palpable dorsalis pedis pulse.

What is the most appropriate next step in management?

Emily Zhou, aged 40, presents with fever, flank pain, and dysuria. She reports feeling unwell for 2 days with nausea and vomiting.

On examination: T 38.9°C, HR 110/min, costovertebral angle tenderness on right side. Urine dipstick positive for nitrites and leukocytes.

What is the most appropriate management?

Jason Wyatt, aged 59, presents with sudden onset severe headache and vomiting. He is hypertensive and has a known intracranial aneurysm under surveillance. He is now drowsy and photophobic.

On examination: T 37.0°C, HR 92/min, BP 160/90 mmHg. GCS 13. Neck stiffness is present.

What is the most appropriate initial investigation?

Lucas Kelly, aged 6, is brought in after a prolonged tonic-clonic seizure lasting over 7 minutes. He has no prior seizure history. He is post-ictal but has normal vital signs.

On examination: HR 110/min, T 37.4°C, RR 20/min. Pupils equal and reactive. No meningism or focal deficits.

What is the most appropriate next step?

Maria Antic, aged 36, presents with nausea, confusion and seizures. She has been taking hydrochlorothiazide for hypertension. Labs show Na 118 mmol/L, K 4.0 mmol/L, creatinine 78 µmol/L.

On examination: GCS 11, no focal neurology.

What is the most appropriate next step?

Jacob Singh, aged 47, presents with central chest pain and vomiting. ECG shows ST elevation in V1-V4. He is hypotensive with cold extremities.

On examination: BP 85/60 mmHg, HR 110/min, elevated JVP, clear lungs.

What is the most likely complication causing his hypotension?

Freya Dawson, aged 50, presents with abdominal pain and vomiting. She had gastric bypass surgery 2 years ago. The pain began suddenly and is severe, central and colicky in nature.

On examination: HR 105/min, BP 115/75 mmHg, distended abdomen, bowel sounds are high-pitched.

What is the most likely diagnosis?

Andrew Holmes, aged 44, presents with fever, malaise and a painful, swollen left leg. He is a cattle farmer and reports a minor abrasion from barbed wire 3 days ago.

On examination: T 39.0°C, HR 115/min, BP 100/60 mmHg. The leg is red, swollen, warm and exquisitely tender with bullae forming. Crepitus is noted.

What is the most appropriate next step in management?

Lily Chen, aged 8, is brought in with high fever, sore throat and muffled voice. She has difficulty swallowing and prefers to sit leaning forward. No cough is reported.

On examination: T 39.3°C, HR 120/min, drooling is present. Throat exam is limited due to distress.

What is the most likely diagnosis?

Zane Roberts, aged 27, presents after a fall while rock climbing. He has severe left-sided chest pain and dyspnoea. On examination: decreased breath sounds on the left, subcutaneous emphysema, and O2 saturation 89% on room air.

CXR shows large left-sided pneumothorax with mediastinal shift.

What is the most appropriate immediate management?

Isobel Grant, aged 35, presents with fatigue, dizziness, and vague abdominal pain. She reports nausea, weight loss, and increased skin pigmentation. She recently recovered from a flu-like illness.

On examination: BP 85/60 mmHg, HR 102/min, hyperpigmentation noted on palmar creases.

What is the most appropriate investigation to confirm the diagnosis?

Michael D’Souza, aged 19, presents with left testicular pain for 4 hours. The pain began suddenly while playing soccer. He is nauseated and distressed.

On examination: Left testis is swollen, high-riding and tender. Cremasteric reflex is absent on the left.

What is the most appropriate next step?

Sarah Blackwell, aged 30, is brought in after being found unconscious in her bedroom with an empty bottle of amitriptyline nearby. On arrival, she is drowsy, HR 130/min, BP 90/60 mmHg, RR 10/min, and QRS widening is noted on ECG.

What is the most appropriate next step in management?

Jeremy O’Neill, aged 52, presents with severe central abdominal pain radiating to the back. He has a history of chronic alcohol use. Lipase is elevated, and CT shows pancreatic oedema without necrosis.

What is the most appropriate management?

Elijah Thomas, aged 40, presents with acute confusion, tremor, visual hallucinations and diaphoresis. He has a long-standing history of alcohol use and last drank 48 hours ago.

Vitals: T 37.8°C, HR 120/min, BP 145/90 mmHg. GCS 14, no focal neurological signs.

What is the most appropriate management?

Amira El-Sayed, aged 24, presents after accidental industrial chemical exposure with organophosphate pesticide. She is salivating, vomiting, has pinpoint pupils and bradycardia.

What is the most appropriate antidote?

Aaron Matthews, aged 68, presents with sudden onset speech disturbance and right-sided weakness. Symptoms began 90 minutes ago. CT brain is normal. BP 148/85, HR 82/min.

What is the most appropriate next step?