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

“Hello, my name is Phil. I am one of the medical students”.

“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.”

“Are you comfortable? Do you need any pain relief or a drink?”

“I have been asked to examine you to assess whether your thyroid maybe causing any of your symptoms. This will involve me: examining your hands; face; neck; legs and reflexes. Is this ok with you?”

“I will talk out loud as we go”

“If at any time you want me to stop or you are in pain, let me know”

“Can you briefly tell me why you have come to hospital?”

“I am looking at the patient for signs of…”

  • Flushing
  • Loss of outer ⅓ eyebrow
  • Tremor
  • Obvious eye signs
  • Neck swelling or scars around the neck 
  • Body habitus

“I am feeling for…”

  • warmth
  • clamminess
  • the pulse (rate; rhythm; quality)

“I am looking for…”

  • Tremor (hold hands out)
  • Nail changes (onycholysis; thyroid acropachy)
  • Palmar erythema
  • Thick coarse skin

Other observations

  • BP
  • Resp Rate
  • Sats
  • Temperature
  • Blood glucose

“I am looking for…”

  • Eyebrow: loss of outer ⅓ 
  • Eye signs:
    • lid retraction
    • Lid lag on downward gaze (“Please look down for me“)
    • Proptosis (“I will assess by looking from the side and down”)
  • Eye movements: “Please follow my finger with your eyes and tell me if you get any double vision.”

Inspection

“I am looking at the neck from the front and side for masses/swellings or scars”

Palpation

“I need to feel your neck:

  • Trachea central?
  • Masses: size; shape; nodule; diffuse
  • “Please can you take a sip of water and swallow” (thyroid masses rises on swallow)
  • “Please can you stick out you tongue” (thyroglossal cysts will move on sticking the tongue out)
  • I am just going to feel for any other lumps in the neck (Lymph nodes)

Percussion

“I am going to tap along your breast bone (dull on percussion suggests a retrosternal goitre)

Auscultation

“I am just going to listen to the neck” (assessing for bruits)

“Lastly I would like to…”

  • Look at your shins for any evidence of pretibial myxoedema
  • Test your reflexes

“Thank you. That is the end of the examination”

“In summary my working differential diagnosis is…”

“To complete my examination I would like to do the following investigations/tests…”

“Does that sound reasonable to you? Do you have any questions or concerns?”

Additional resources

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