ACC

What is the first line investigation for AAA?

Abdominal Ultrasound

What's the first line investigation for a pneumothorax?

Chest x-ray

A 32-year-old obese, but otherwise healthy, male presents to the emergency department with onset of acute lower abdominal pain of 2-hour duration. He has no fever and there is no history of any previous significant illness, except loud snoring, possible sleep apnoea, and being overweight.

Diverticular disease

What are the first line investigations for pancreatitis?

Transabdominal ultrasound Serum lipase or amylase FBC CRP Urea/creatinine Pulse Ox LFTS CXR Serum Calcium

What's the first line investigation for an ovarian cyst?

Transvaginal ultrasound

What are the first line investigations for miscarriage?

Transvaginal ultrasound Serum beta hCG titres

A 73-year-old woman with a history of myocardial infarction presents to the emergency department. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure is elevated 3 cm above normal and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination. What are your treatments?

(Hypotensive congestive heart failure) Oxygen therapy Ionotrope Vasopressor

A 55-year-old man with a history of hypertension (well controlled with medication) and tobacco use presents to his primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been steadily worsening in intensity. He says the pain radiates to his lower back and both groins at times. While he cannot identify any aggravating factors (such as movement), he feels the pain improves with his knees flexed. There is a palpable pulsatile mass just left of midline below the umbilicus. He is immediately referred for definitive management, but during transfer becomes hypotensive and unresponsive.

Abdominal aortic aneurysm

What are the first line investigations for Cholangitis?

Abdominal ultrasound

What are the first line investigations for Cholelithiasis

Abdominal ultrasound Serum LFTs FBC Serum lipase or amylase

A 6-year-old female without a significant past medical history presents for evaluation of frequent unusual episodes for the past 3 months. The episodes consist of sudden activity arrest with staring and minimal eyelid flutter for 10 to 20 seconds occurring 5 to 10 times per day. The patient is unresponsive to voice or tactile stimulation during the episodes. She is able to immediately resume activities without any recollection of the event once the episode finishes. Her teachers have noted that she stares off in class repeatedly and does not seem to be remembering instructions and classroom material. The diagnosis of attention-deficit/hyperactivity disorder had been suggested. One such unusual episode is induced in front of medical staff with hyperventilation.

Absence Seizure

A 27-year-old woman with a history of moderate persistent asthma presents to the emergency department with progressive worsening of shortness of breath, wheezing, and cough over 3 days. She reports prior exposure to a person who had a runny nose and a hacking cough. She did not receive significant relief from her reliever inhaler, with worsening symptoms, despite increased use. She has been taking her asthma medications regularly, which consist of an inhaled corticosteroid and a leukotriene receptor antagonist for maintenance therapy and salbutamol as reliever therapy. Her cough is disrupting her sleep pattern and as a consequence she is experiencing daytime somnolence, which is affecting her job performance.

Acute exacerbation of asthma

A 67-year-old woman with a history of COPD presents with 3 days of worsening dyspnoea and increased frequency of coughing. Her cough is now productive of green, purulent sputum. The patient has a 100-pack-year history of smoking. She has had intermittent, low-grade fever of 37.7°C (100°F) for the past 3 days and her appetite is poor. She has required increased use of rescue bronchodilator therapy in addition to her maintenance medications to control symptoms.

Acute exacerbation of chronic obstructive pulmonary disease

A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C [100.5°F]), tenderness on palpation at right lower quadrant (McBurney's sign), and leukocytosis (12 x 109/L or 12,000/microlitre) with 85% neutrophils.

Appendicitis

What are the first line investigations for gout?

Arthrocentesis and synovial fluid analysis Consider serum uric acid level and ultrasound

Reasons for atypical/delayed presentation for appendicitis

Atypical anatomy (retrocaecal/long appendix) Age (confusion, general abdo pain, no associated features) Pregnancy (delayed diagnosis)

First line investigations for large bowel obstruction

CT FBC CRP Urea/creatinine Glucose ABG Electrolytes

First line investigations of small bowel obstruction

CT Water soluble contrast study Bloods

What investigations should you consider for diverticular disease?

CT abdo

What are the first line investigations for Cholecystitis?

CT/MRI Abdominal Ultrasound FBC CRP Bilirubin LFTs Serum lipase or amylase Blood cultures and/or bile cultures

A 65-year-old man presents to the emergency department with acute onset of shortness of breath of 30 minutes' duration. Initially, he felt faint but did not lose consciousness. He is complaining of left-sided chest pain that worsens on deep inspiration. He has no history of cardiopulmonary disease. A week ago he underwent a total left hip replacement and, following discharge, was on bed rest for 3 days due to poorly controlled pain. He subsequently noticed swelling in his left calf, which is tender on examination. His current vital signs reveal a fever of 38.0°C (100.4°F), heart rate 112 bpm, BP 95/65 mmHg, and an O₂ saturation on room air of 91%. What are your first line investigations and treatments?

CTPA Anticoagulation

A 45-year-old man presents with acute onset of pain and redness of the skin of his lower leg. Low-grade fever is present and the pretibial area is red, swollen, and tender.

Cellulitis

A 58-year-old man with pancreatic adenocarcinoma, who had a plastic stent placed in his common bile duct 6 weeks ago to relieve obstructive jaundice, presents to the emergency department with a 1-week history of progressive nausea and occasional vomiting after eating. He has generalised abdominal pain that is worse in the RUQ. He has experienced subjective fever/chills and states that his bowel movements are pale. Laboratory results show a WBC of 14.0 × 10⁹/L (14,000/microlitre) (reference range 4.8-10.8 × 10⁹/L or 4800-10,800/microlitre) with 8% (reference range 0% to 4%) bands and PMNs of 77% (reference range 35% to 70%). AST is 214 units/L (reference range 8-34 units/L), ALT is 181 units/L (reference range 7-35 units/L), alkaline phosphatase is 543 units/L (reference range 25-100 units/L), total bilirubin is 183.0 micromol/L (10.7 mg/dL) (reference range 3.4 to 22.2 micromol/L or 0.2 to 1.3 mg/dL), and amylase is 110 units/L (reference range 53-123 units/L).

Cholangitis

A 65-year-old woman presents to the emergency department with a 2-day history of progressive right upper quadrant (RUQ) pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have become loose. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Faecal occult blood test is negative. Laboratory results show a WBC of 18.0 × 10⁹/L (18,000/microlitre) (reference range 4.8-10.8 × 10⁹/L or 4800-10,800/microlitre) with 17% (reference range 0% to 4%) bands and PMNs of 82% (reference range 35% to 70%). AST is 207 units/L (reference range 8-34 units/L), ALT is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 107.7 micromol/L (6.3 mg/dL) (reference range 3.4 to 22.2 micromol/L or 0.2 to 1.3 mg/dL), and amylase is 82 units/L (53-123 units/L).

Cholangitis

A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.

Cholecystitis

A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to hospital for neurological evaluation.

Febrile Seizure

A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the right upper quadrant (RUQ) that radiates through to her back. This pain began after eating dinner, gradually increased, and has remained constant over the last few hours. She has experienced previous episodes of similar pain for which she did not seek medical advice. Her vital signs are normal. The pertinent findings on physical examination are tenderness to palpation in the RUQ without guarding or rebound.

Cholelithiasis

A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical examination reveals a temperature of 38.3°C (101°F), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. Chest x-ray reveals a left lower lobe infiltrate.

Community-acquired pneumonia

A 20-year-old man is brought to the accident and emergency department with abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the previous day. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67 mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per minute, temperature 37.1°C (98.8°F). On mental status examination, he is drowsy. Physical examination reveals Kussmaul's breathing (deep and rapid respiration due to ketoacidosis) with acetone odour and mild generalised abdominal tenderness without guarding and rebound tenderness. Initial laboratory data are: blood glucose 25.0 mmol/L (450 mg/dL), arterial pH 7.24, PCO2 25 mmHg, bicarbonate 12 mmol/L (12 mEq/L), WBC count 18.5 × 10⁹/L (18,500/microlitre), sodium 128 mmol/L (128 mEq/L), potassium 5.2 mmol/L (5.2 mEq/L), chloride 97 mmol/L (97 mEq/L), serum urea 11.4 mmol/L (32 mg/dL), creatinine 150.3 micromol/L (1.7 mg/dL), serum ketones strongly positive.

DKA

A 65-year-old woman presents with unilateral leg pain and swelling of 5 days' duration. There is a history of hypertension, congestive heart failure, and recent hospitalisation for pneumonia. She had been recuperating at home but on beginning to mobilise and walk, the right leg became painful, tender, and swollen. On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left. There is tenderness on palpation in the popliteal fossa behind the right knee.

Deep vein thrombosis

A 57-year-old female with a history of hypertension and hypercholesterolaemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant gastrointestinal problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for gastrointestinal disorders.

Diverticular disease

A 25-year-old woman with a history of depression is brought to hospital with altered mental status and a brief seizure. She is obtunded and tachycardic to 127 bpm and her blood pressure is 96/62 mmHg. She appears flushed and is arousable only to vigorous stimulation. Her skin is warm and dry. Pupils are 5 to 6 mm and poorly reactive to light. What are the first line investigations and treatments?

ECG Sodium bicarbonate therapeutic trial ABG Supportive care and monitoring (?)GI Decontamination (?)Sodium bicarb bolus and infusion (?)Anti-arrythmic (?)IV fluids, vasopressor or glucagon or extracorporeal membrane oxygenation (?)Hyperventilation (?)Benzodiazepine, barbiturate or propofol

A 23-year-old nulligravida presents with a 2-day history of sharp intermittent right lower quadrant abdominal pain, non-radiating, without any alleviating factors, exacerbated with movement, progressively worsening, and not associated with any gastrointestinal symptoms. Her last menstrual period was 7 weeks ago. She denies medical problems. Her gynaecological history is significant for a prior chlamydial infection as a teenager, but is otherwise negative.

Ectopic pregnancy

A 33-year-old gravida 3 para 2 presents with 4-day history of vaginal bleeding along with lower abdominal discomfort and nausea. She states that her symptoms have worsened over the previous 24 hours. Her last menstrual period was 6 weeks ago. She denies medical, gynaecological, or social problems and her review of systems is negative except for the above complaints. Her obstetrical history includes an abortion and two uncomplicated vaginal deliveries followed by an interval tubal ligation 1 year ago.

Ectopic pregnancy

What are the first line investigations for appendicitis?

FBC CRP Abdominal ultrasound Contrast-enhanced abdominal CT

What are the first line investigations for cellulitis?

FBC ESR CRP Urea and electrolytes Blood culture and sensitivities

A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with paracetamol and ibuprofen at home. The child then began to have frequent jerking movements of all limbs. The rectal temperature was 39.5°C (103.1°F). The parents called the emergency services, and a paracetamol suppository was administered during transport to the emergency department. The jerking stopped after approximately 5 minutes. Afterwards, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurological status.

Febrile Seizure

A 70-year-old man presents with a tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond when spoken to, mumbles words that do not make sense, and stares in a motionless way. After several minutes he is usually responsive. His past medical history includes hypertension and hypercholesterolaemia. He had a stroke during the preceding year, which resulted in weakness of the right extremities and loss of expressive language. Although he recovered most motor and language deficits, he still walks with a limp on the right side and sometimes uses the wrong word.

Focal Seizure

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that during these episodes she smacks her lips, picks at her clothing, and is unable to speak. After the event she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.

Focal Seizure

A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterwards. Further review of the history reveals that the patient has been experiencing 'jerks' in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These 'jerks' do not seem to present a problem during the rest of the day.

Generalised Seizure

A 55-year-old woman recently diagnosed with a brain tumour in the left hemisphere has a witnessed seizure event. The seizure is initially recognised when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic extension of the right arm and flexion of the left arm. This is quickly followed by tonic extension of the left arm as well, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.

Generalised Seizure

A 10-year-old girl presents after having had a generalised tonic-clonic seizure while at school the previous day. It lasted approximately 2 minutes and she was incontinent of urine during the episode. Afterwards she complained of headache and feeling tired. She had been well prior to this episode and there is no family history of epilepsy. General physical examination including neurological assessment on the day after the seizure were both normal. An ECG was done, which was normal and showed a normal QTc interval.

Generalised seizures in children

A 15-year-old boy presents with a history of having had two seizures. He is healthy and has no relevant past medical history. There is no family history of epilepsy. Both episodes happened early in the morning and were self-limiting. Jerking of the whole body and all four limbs lasted <5 minutes, and he was sleepy for several hours after the episodes. His general examinations, including blood pressure, a random blood sugar, and an ECG, were normal.

Generalised seizures in children

A 54-year-old man complains of severe pain and swelling in his right first toe that developed overnight. He is limping because of the pain and states that this is the most severe pain he has ever had ('even covering my foot with the bed sheet hurts'). He has had no previous episodes. His only medication is hydrochlorothiazide for hypertension. He drinks 2 to 3 beers a day. On examination, he is obese. There is swelling, erythema, warmth, and tenderness of the right first toe. There is also tenderness and warmth with mild swelling over the mid foot.

Gout

An 85-year-old man presents with several days of swelling and severe pain in both hands limiting his ability to use his walking frame. He has a history of gout but has not experienced these symptoms before. On examination, he has a temperature of 37.8°C (100.1°F). There is diffuse warmth, mild erythema, and pitting oedema over the dorsum of both hands. There is tenderness and limited hand grip bilaterally. There are multiple nodules around several of the proximal interphalangeal and distal interphalangeal joints, and effusion and tenderness in his left olecranon bursa with palpable nodules.

Gout

A 55-year-old man with a history of peripheral vascular disease, who presents with a complaint of a left foot ulcer and pain when walking short distances, is found to have a popliteal stenosis and admitted for re-vascularisation. Four days after admission, on postoperative day 3, he develops shortness of breath, hypoxia, and a productive cough. Auscultation of his chest reveals decreased breath sounds at the lower aspect of the right side of his chest. His morning leukocyte count is slightly higher than the day before at 11,000 cells/mL3. An anterior-posterior bedside chest x-ray reveals right lower lobe opacity.

Hospital-acquired pneumonia

An 88-year-old female resident of a nursing home, who typically does not present to the acute care hospital, has frequent urinary tract infections (UTIs) that are managed by the nursing home physician. In the nursing home, she develops a UTI due to multidrug-resistant pathogens. On admission to hospital, she has poor mental status and her bed is left with the head elevated to only a 5° angle. On hospital day 4, a chest x-ray reveals a right lower lobe opacity.

Hospital-acquired pneumonia

A 45-year-old man with a history of type 2 diabetes is admitted directly from clinic for a serum glucose of 53.8 mmol/L (970 mg/dL). He was started recently on basal bolus insulin therapy after several years of treatment with oral antiglycaemic agents. However, he reports not having followed his insulin prescription because he struggles to inject himself. For the past 2 weeks he has had polyuria and polydipsia, and has lost 5 kg in weight. He has also noted a progressively worsening cough for approximately 3 weeks that is productive of greenish-brown sputum. On examination, he is febrile, with a temperature of 38.5°C (101.3°F), tachypnoeic (respiratory rate of 24 breaths per minute), and normotensive. Urinalysis reveals trace ketones, but serum beta-hydroxybutyrate is not elevated. Serum bicarbonate is 17 mmol/L (17 mEq/L), and venous pH is 7.32.

Hyperglycaemic Hyperosmolar State

A 72-year-old man is brought to hospital from a nursing home for progressive lethargy. The patient has a history of hypertension complicated by a stroke 3 years previously. This has impaired his speech and rendered him wheelchair-bound. He also has schizophrenia for which he was started recently on clozapine. On presentation, he is disoriented to time and place and febrile, with a temperature of 38.3°C (101°F). Vital signs include a BP of 106/67 mmHg, heart rate of 106 beats per minute, and a respiratory rate of 32 breaths per minute. Initial laboratory work-up reveals a serum glucose of 52.7 mmol/L (950 mg/dL), a serum sodium of 127 mmol/L (127 mEq/L), a serum urea of 21.1 mmol/L (59 mg/dL), and a serum creatinine of 200 micromol/L (2.3 mg/dL). Serum osmolality is calculated as 338 mOsm/kg (338 mmol/kg). Urinalysis reveals numerous white blood cells and bacteria. Urine is positive for nitrates but negative for ketones. Serum is negative for beta-hydroxybutyrate.

Hyperglycaemic Hyperosmolar State

How are most abdominal aortic aneurysms detected?

Incidentally

A 32-year-old woman has just been confirmed by ultrasound scan as pregnant with twins at a gestational age of 10 weeks. She had been trying for a pregnancy for the past 5 years, but has had no sub-fertility treatment. On her way home, she notices bright red vaginal bleeding. She is not in any pain. She has no postural dizziness.

Miscarriage

A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.

Ischaemic stroke

A 62-year-old woman presents for a routine annual evaluation to her primary care physician. She is being treated for hypertension and diabetes. She smokes 20 cigarettes per day. She has undergone coronary artery bypass grafting subsequent to unstable angina 2 years ago. She does not recollect an episode of sensory or motor deficit or of monocular blindness. She has a regular heart rhythm with a loud systolic bruit audible over her right neck. She has no demonstrable motor or sensory deficits on physical examination. Duplex ultrasonography is consistent with a 50% stenosis of the right internal carotid artery.

Ischaemic stroke (carotid artery stenosis)

A 72-year-old man presents with sudden onset of left arm weakness and numbness. He is being treated for hypertension and diabetes, and smokes 20 cigarettes per day. He has undergone coronary artery stenting subsequent to a myocardial infarction 2 years ago. He has a regular heart rhythm. Duplex ultrasonography is consistent with a >80% stenosis of the right internal carotid artery. Contrast-enhanced computed tomography demonstrates a right frontoparietal infarction without evidence of intracranial haemorrhage.

Ischaemic stroke (carotid artery stenosis)

A man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination.

Large bowel obstruction

A 45-year-old man presents to the emergency department with a 1-hour history of sudden onset of left-sided flank pain radiating down towards his groin. The patient is writhing in pain, which is unrelieved by position. He is nauseous and has been vomiting.

Nephrolithiasis

What are the first line investigations for Nephrolithiasis?

Non-contrast helical CT Renal ultrasound (pregnant or child) Urinalysis FBC Serum electrolytes, urea, creatinine Pregnancy test

A 27-year-old woman (gravida 2, para 2) presents to her general practitioner with a chief complaint of pelvic pain. The pain began about 3 weeks previously and is characterised as dull with a pressure-like fullness in the right pelvis. The pain is exacerbated by some movements and by sexual intercourse. She noted no change in intensity or character with her last menses 2 weeks previously. Her past gynaecological and medical histories are unremarkable. Previous surgeries include one caesarean delivery and an appendectomy. Review of symptoms reveals some increased frequency of urination but no other notable menstrual, haematological, gastrointestinal, or genitourinary symptoms. Physical examination reveals a well-nourished female in no acute distress who demonstrates mild tenderness on deep palpation of the right lower quadrant of her abdomen. On pelvic examination, palpation of the right adnexa elicits moderate tenderness.

Ovarian Cyst

A 58-year-old obese post-menopausal woman (gravida 4, para 3) presents to her annual gynaecological visit without initial complaint. During the interview, she denies post-menopausal bleeding but acknowledges increased abdominal bloating and early satiety. Over the past year, she has experienced pelvic and low back pain that is mildly bothersome but worsening. Her family history is notable for a sister with breast cancer and mother with an unknown female cancer. Abdominal examination is non-diagnostic due to her body habitus, and pelvic examination is limited. There is concern for a vague fullness that is appreciated on rectovaginal examination.

Ovarian cyst

A 47-year-old overweight woman is admitted with generalised abdominal pain. She has been unable to eat or drink due to nausea and vomiting. She states the pain started in the right upper quadrant, similar to previous episodes that she had been to the emergency department with over the past few months. An ultrasound obtained on her last visit to the emergency department revealed gallstones with no inflammation of the gallbladder, and she was told that she should see a surgeon. She looks jaundiced and in distress. She has point tenderness under her ribs on the right, which is worsened with deep palpation. No mass is palpable.

Pancreatitis

A 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic with decreased breath sounds over the base of the left lung.

Pancreatitis

An 18-year-old female university student with a history of prior chlamydia infection presents with low-grade fever and non-specific lower abdominal pain. Examination reveals mild diffuse lower abdominal tenderness on deep palpation. She has cervical motion tenderness and a mucopurulent vaginal discharge on pelvic examination.

Pelvic inflammatory disease

A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by famotidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole. Physical examination reveals a fit, apparently healthy man in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen.

Peptic ulcer disease

What are the first line investigations for an ectopic pregnancy?

Pregnancy test Transvaginal or transabdominal ultrasound

A 20-year-old man presents to the emergency department with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he might have strained a chest wall muscle, but because the pain and dyspnoea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular examination is normal.

Pneumothorax

A 65-year-old patient with COPD presents to the emergency department with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the colour or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.

Pneumothorax

A 25-year-old man who is a known intravenous drug misuser presents with a 5-day history of pain and swelling in his right leg. On examination there are multiple sites of intravenous puncture. His right leg is swollen from the knee downwards. There is a large effusion on the right knee together with significant cellulitic changes of the overlying skin.

Septic arthritis

A 55-year-old woman presents with a 1-week history of pain and swelling in her left wrist. She was diagnosed with rheumatoid arthritis at the age of 36 years but the rest of her joints are currently asymptomatic. Her rheumatoid arthritis is well controlled on her current medication. On examination her left wrist is found to be hot, swollen, tender, and highly restricted in its range of movement. There is no sign of inflammation in any of her other joints. She has a temperature of 37.5˚C (99.5˚F).

Septic arthritis

A 38-year-old woman presents with nausea and pain from a tooth abscess. On further questioning she states that she has been ingesting small handfuls of paracetamol-containing pills every few hours over the previous 2 to 3 days. What are the first line investigations and treatments?

Serum paracetamol LFTs Prothrombin time and INR Blood glucose urea, creatinine and electrolytes VBG FBC Supported care (?) Acetylcysteine (?) Anti-emetic

A 78-year-old man with a history of hypertension presents to his primary care physician with 1 episode of dizziness while watching television. On physical examination, his heart rate is measured at about 40 bpm. A 12-lead ECG is obtained showing sinus rhythm at about 75 bpm and complete heart block with a wide escape rhythm at about 40 bpm. On further questioning, the patient admits to increasing fatigue and dyspnoea on exertion for the past few weeks. Notably, the patient has bifascicular block at baseline (right bundle-branch block and left anterior fascicular block). What are your first line investigations and treatments?

Serum troponin, potassium, calcium, pH and digitalis levels. Condition specific management, discontinuation of AV node-blocking drugs ± temporary transcutaneous or transvenous pacing PPM or Cardiac resynchronisation therapy ± ICD placement

A 27-year-old male presents with cramping abdominal pain of sudden onset, emesis, and failure to pass any flatus or stool for 24 hours. The patient has no history of prior surgery. Physical examination reveals peritonitis. Computed tomography reveals the level of the obstruction.

Small bowel obstruction

A 43-year-old female with a prior history of open cholecystectomy presents with gradual onset of nausea, vomiting, absolute constipation, and abdominal distention. Physical examination does not demonstrate peritonitis. Computed tomography is used to confirm the diagnosis.

Small bowel obstruction

A 45-year-old woman was having dinner when she felt the sudden onset of a severe headache, unlike anything she had ever experienced. She vomited many times before her husband brought her to seek medical attention. On presentation she requires stimulation to maintain alertness and has mild nuchal rigidity. Her blood pressure is elevated but examination is otherwise normal. CT of the brain reveals subarachnoid blood in the anterior interhemispheric fissure. Angiography reveals a 7-mm aneurysm in the anterior communicating artery.

Stroke (Cerebral aneurysm)

An anxious 30-year-old woman seeks medical attention because of recent worsening headaches and visual disturbances. She is a smoker and has a sibling who was admitted to hospital for a ruptured cerebral aneurysm. Examination discloses slight ptosis of the left eye. On neurological examination, her left pupil is dilated, minimally reactive to light, and pointing inferiorly and laterally at rest. CT of the brain shows no subarachnoid blood. Lumbar puncture is normal. Magnetic resonance angiography of the brain reveals a 5-mm aneurysm in the left posterior communicating artery.

Stroke (Cerebral aneurysm)

A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.

Stroke (spontaneous intracerebral haemorrhage)

A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid haemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness. Brain computed tomography (CT) reveals diffuse subarachnoid blood in basal cisterns and sulci.

Stroke (subarachnoid haemorrhage)

A 45-year-old man presents to the emergency department with restlessness and tremors. He is anxious and pacing in the hallway. Initial vital signs show a heart rate of 121 beats per minute and blood pressure of 169/104 mmHg; other vital signs are normal. On further questioning by the nurse he states that he is nauseous and wants something to help with 'the shakes'. During the consultation the patient admits to heavy alcohol use and that he is trying to cut down on drinking. He also says that his current symptoms started to develop about 6 hours after his last drink. What are your first line treatments?

Supportive care Thiamine Consider benzodiazepine or carbamazepine or clomethiazole

What are the first line investigations for septic arthritis?

Synovial fluid microscopy/cultures/white cell count Blood cultures White cell count ESR CRP Urea and electrolytes LFTs

A 21-year-old man presents to the emergency department with central nervous system depression, respiratory depression, and miosis (1 mm pupils). Friends state that the patient was seen injecting himself at a party, at which time he became unresponsive. He is deeply unresponsive to pain and gives no history. The patient is a known drug user. He has track marks on both upper extremities and syringes are found among his belongings. What are the first line investigations and treatments?

Therapeutic trial of naloxone, ECG Ventilation and naloxone (Whole bowel irrigation (drug mule))

A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the accident and emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.

Transient Ischaemic attack

What is the difference between type A and B AAA

Type A is ascending aorta, B is descending and below

A 59-year-old man complains of urinary frequency, urgency, and dysuria for several days. He denies the presence of haematuria or penile discharge, but does have 3 episodes of nocturia most nights. His past medical history includes benign prostatic hyperplasia (BPH). The patient is in a monogamous relationship with his wife.

UTI

A 70-year-old man, who has been an inpatient for 4 days with an exacerbation of congestive heart failure, is now complaining of unilateral back pain. He has had an indwelling urinary catheter to strictly monitor urine output since admission. He also relates a history of increasing suprapubic discomfort for the last 24 hours. Examination confirms fever, suprapubic tenderness, and costovertebral angle tenderness.

UTI

What are the first line investigations for peptic ulcer disease?

Upper GI endoscopy Helicobacter breath test or stool antigen FBC

What's the first line investigation for UTIs?

Urine dipstick

A 32-year-old white man presents to the emergency department after smoking metamfetamine. He was discovered by police ingesting (body stuffing) several packets of materials to prevent detection. On examination, the patient is agitated and has multiple skin excoriations and scars on his hands and upper arms. His pupils are dilated and he is grinding his teeth. He is hypertensive, mildly hyperthermic, and tachycardic. An initial urine drug toxicology screen is positive for amfetamines. An ECG shows sinus tachycardia with evidence of left ventricular hypertrophy. An abdominal flat-plate x-ray shows several metallic areas, indicating folded aluminium metamfetamine packets. What are the first line investigations and treatments?

Urine tox test Gas chromatography / mass spec of urine or blood ECG Sodium Creatinine phosphokinase Abdo X-ray Activated charcoal, sedative/antipsychotic(?) psychosocial and behavioural treatment, pharmacotherapy, antidepressant(?)

A 60-year-old man presents with syncope while walking outside with his wife. His wife recalls the patient looking at the sky to point out an aeroplane. He then appeared pale and collapsed to the ground, suffering a head laceration in the process. The history suggested the possibility of carotid sinus syndrome (CSS). In the laboratory, carotid sinus massage was undertaken while the patient was in the upright posture on a tilt table. The massage induced 10 seconds of asystole with near loss of consciousness. A dual-chamber pacemaker was implanted on the basis of a presumptive diagnosis of CSS; there was no recurrence of syncope during the next year. This patient has had no further faints but occasionally becomes dizzy when turning his head abruptly (CSS).

Vasovagal Syncope

An 18-year-old man presents to a clinic reporting 2 episodes of loss of consciousness. The first episode occurred 1 year earlier while playing dodge ball in gym class. He recalls diving to the ground to avoid being hit. On getting up quickly, he noticed feeling lightheaded, sweaty, and nauseated. Apparently, he fell to the ground but does not recall having done so. He later recalls waking up in an accident and emergency (A&E) department. Witnesses reported shaking and clenching of both hands after he had fallen. In the A&E department he was given phenytoin intravenously because of concern that he may have had a seizure. After a negative work-up in the hospital he was prescribed carbamazepine, despite no abnormalities on an electroencephalogram. A year later he had a second episode of loss of consciousness while doing bicep curls. He denies palpitations, tongue biting, or incontinence. He experienced a similar prodrome of warmth and lightheadedness. He has no history of seizures outside of these 2 episodes (vasovagal syncope).

Vasovagal Syncope

What are the first line investigations for a DVT?

Wells' score Quantitative D-dimer level Ultrasound INR and apTT Urea and creatinine LFTS FBC