Pick ‘n’ Mix – Week 2 March 2023

Estimated Reading Time: 4 minutes

We are really grateful to Trudie Pestell for sharing Pick ‘n’ Mix: a fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department.

Each week we will bring you some clinical pearls to add to your knowledge and understanding with links to other resources as well as an OSCE of the week.

Presentation

A 55 year old female presents to the ED with abdominal pain. It has been occurring after meals for some weeks and over the past 24 hours has become persistent and severe. She has a soft non tender abdomen. CT reveals a mesenteric artery occlusion.

Pathophysiology

Due to a sudden decline in blood flow through the mesenteric vessels – most commonly due to arterial embolism affecting the superior mesenteric artery. Can be caused by any condition causing embolism or thrombosis e.g AF, atherosclerosis. Notably, certain drugs, such as vasopressors and cocaine, can cause a non-occlusive mesenteric ischaemia.

Epidemiology

Due to a sudden decline in blood flow through the mesenteric vessels – most commonly due to arterial embolism affecting the superior mesenteric artery. Can be caused by any condition causing embolism or thrombosis e.g AF, atherosclerosis. Notably, certain drugs, such as vasopressors and cocaine, can cause a non-occlusive mesenteric ischaemia.

Symptoms and Signs

Moderate-to-severe colicky or constant and poorly localised pain out of proportion to clinical findings. In the later stages typical symptoms of peritonism develop A history of postprandial pain is common.

Investigations – Early suspicion is key

  • CT angiography is the gold standard
  • There are no specific laboratory tests in the diagnosis of mesenteric ischaemia

Management

  • Fluid resuscitation
  • Broad spectrum antibiotics
  • Consider unfractioned heparin
  • Surgical referral – this may include angiography or surgical resection.

The case of an oozing ear

The beginning:

A 56-year-old female with diabetes attends ED with a 2-week history of ear pain that has been unresponsive to antibiotics. It has more recently started discharging, she feels generally unwell and she reports feeling that her facial muscles are weak and she has difficulty swallowing.

Malignant otitis externa– Malignant (necrotizing) external otitis (also termed malignant otitis externa) is an invasive infection of the external auditory canal and skull base, which typically occurs in older adult patients with diabetes mellitus. Increasing reports of malignant external otitis in patients infected with the human immunodeficiency virus (HIV) implicate a compromised immune system as a predisposing factor in this disease.

More information is available on the excellent UpToDate

OSCE of the Week – Thyroid Examination

Introduction

Brief history

General inspection

Hands and other observations

Face

Neck

Lower limb reflexes

Close

Additional resources

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