SBAs for the FRCEM [1 ed.] 9781009001670, 9781009003834, 1009001671, 9781009020404

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SBAs for the FRCEM

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Published online by Cambridge University Press

SBAs for the FRCEM Tom Jaconelli MB BS DLM FRCEM FHEA Consultant in Emergency Medicine, York Teaching Hospitals NHS Foundation Trust Honorary Senior Lecturer, Hull York Medical School

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University Printing House, Cambridge CB2 8BS, United Kingdom One Liberty Plaza, 20th Floor, New York, NY 10006, USA 477 Williamstown Road, Port Melbourne, VIC 3207, Australia 314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre, New Delhi – 110025, India 103 Penang Road, #05–06/07, Visioncrest Commercial, Singapore 238467 Cambridge University Press is part of the University of Cambridge. It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence. www.cambridge.org Information on this title: www.cambridge.org/9781009001670 DOI: 10.1017/9781009003834 © Cambridge University Press 2022 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2022 A catalogue record for this publication is available from the British Library. ISBN 978-1-009-00167-0 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. The author does not accept any liability for any errors or omissions. Clinicians should always consult up-to-date guidelines and evidence when making treatment decisions. No scenario is based on a real patient.

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For my Mum and Dad, Sue and Eddie, Thank You.

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Contents Preface ix Acknowledgements xii

Paper 1

Paper 4

Questions 1 Answers 14

Questions 91 Answers 104

Paper 2

Paper 5

Questions 29 Answers 42

Questions 121 Answers 134

Paper 3 Questions 61 Answers 74

Index 150

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Preface In August 2021, the Royal College of Emergency Medicine (RCEM) launched the 2021 emergency medicine curriculum and revised the suite of examinations for postgraduate doctors. From this date, the membership examination comprises a primary single best answer (SBA) basic sciences examination, intermediate SBA clinical examination and an objective structured clinical examination (OSCE). The fellowship examination comprises an OSCE and an SBA clinical examination. The fellowship SBA examination comprises two papers, each containing 90 questions, with two hours to complete each paper. This book aims to provide a revision tool for those sitting the fellowship SBA examination. It contains 200 SBA questions and answers, with explanations. All of the answers are fully referenced to up-to-date guidelines and literature to allow for further reading. The examination is based upon the following speciality learning outcomes and syllabus categories:1 • Care for physiologically stable patients attending the emergency department (ED) across the full range of complexity ◦ Allergy ◦ Cardiology ◦ Dermatology ◦ Ear, nose and throat ◦ Elderly care ◦ Endocrinology ◦ Environmental emergencies ◦ Gastroenterology and hepatology ◦ Haematology ◦ Infectious diseases ◦ Maxillofacial/dental ◦ Mental health ◦ Musculoskeletal (non-traumatic) ◦ Nephrology 1

RCEM. Regulation and Information Pack: FRCEM Final Examinations. February 2022, https://rcem.ac.uk/wp-content/uploads/2022/03/FRCEM_Final_Information_and_reg ulations_2021.3.pdf (accessed 29 March 2022). ix

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◦ Neurology ◦ Obstetrics and gynaecology ◦ Oncological emergencies ◦ Ophthalmology ◦ Pain and sedation ◦ Palliative and end-of-life care ◦ Pharmacology and poisoning ◦ Respiratory ◦ Sexual health ◦ Surgical emergencies ◦ Urology ◦ Vascular • Resuscitate and stabilise patients in the ED, knowing when it is appropriate to stop ◦ Resuscitation ◦ Palliative and end-of-life care ◦ Trauma ◦ Other clinical presentations • Care for injured patients across the full range of complexity ◦ Pain and sedation ◦ Major trauma ◦ Other clinical presentations • Care for children of all ages in the ED, at all stages of development and with complex needs ◦ Dermatology ◦ Ear, nose and throat ◦ Gastroenterology and hepatology ◦ Infectious diseases ◦ Musculoskeletal (non-traumatic) ◦ Neonatal emergencies ◦ Neurology ◦ Ophthalmology ◦ Respiratory ◦ Resuscitation ◦ Safeguarding and psycho-social emergencies in children ◦ Surgical emergencies

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• Proficiently deliver key procedural skills needed in emergency medicine ◦ Adult sedation ◦ Paediatric sedation ◦ Pericardiocentesis ◦ Non-invasive ventilation ◦ Escharotomy ◦ Lumbar puncture • Deal with complex or challenging situations in the workplace ◦ Medicolegal ◦ Legislation ◦ Organ/tissue donation ◦ Information governance ◦ Safeguarding • Lead the ED shift ◦ Patient flow management ◦ Risk management ◦ Clinical governance • Participate in research and manage data appropriately ◦ Diagnostic methodology ◦ Randomised controlled trials ◦ Systematic review ◦ Statistical techniques • Participate in and promote activity to improve the quality and safety of patient care ◦ Quality improvement theories and methodologies ◦ Principles of measurement for improvement, judgement and research ◦ Measures and methods of assessing variation • Manage, administer and lead ◦ Serious adverse event investigation tools ◦ Complaint management

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Acknowledgements

I am indebted to Professor Joseph Jaconelli and Dr Robert Taylor for their invaluable comments and critique of the manuscript, and to Catherine Barnes and Kim Ingram at Cambridge University Press for their support and guidance. Finally, to Beth for her love, support and patience.

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Paper 1

Questions

Question 1 You are working in the paediatric emergency department. A four-year-old girl is waiting to see the triage nurse following a wrist injury. The mother gives the child a packet of nuts to eat. Shortly afterwards, she develops a widespread rash, swelling of the lips and tongue, and becomes short of breath. The child is brought straight to the resuscitation area. What dose of intramuscular (IM) adrenaline should be administered? A. 500 mcg B. 300 mcg C. 200 mcg D. 150 mcg E. 75 mcg

Question 2 A 60-year-old male, with known left bundle branch block (LBBB) on his electrocardiogram (ECG), presents with chest pain. You are asked to review his ECG taken at triage. What ECG changes make the likelihood of an acute myocardial infarction more likely in the context of pre-existing LBBB? A. Concordant ST-segment elevation of at least 1 mm in at least one lead B. Concordant ST-segment elevation of at least 3 mm in at least two leads C. Concordant ST-segment depression of at least 3 mm in leads V1, V2, or V3 D. Concordant ST-segment depression of at least 4 mm in leads V1, V2, or V3 E. Excessively discordant ST-segment elevation of 2 mm when the QRS result is negative

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Paper 1

Questions

Question 1 You are working in the paediatric emergency department. A four-year-old girl is waiting to see the triage nurse following a wrist injury. The mother gives the child a packet of nuts to eat. Shortly afterwards, she develops a widespread rash, swelling of the lips and tongue, and becomes short of breath. The child is brought straight to the resuscitation area. What dose of intramuscular (IM) adrenaline should be administered? A. 500 mcg B. 300 mcg C. 200 mcg D. 150 mcg E. 75 mcg

Question 2 A 60-year-old male, with known left bundle branch block (LBBB) on his electrocardiogram (ECG), presents with chest pain. You are asked to review his ECG taken at triage. What ECG changes make the likelihood of an acute myocardial infarction more likely in the context of pre-existing LBBB? A. Concordant ST-segment elevation of at least 1 mm in at least one lead B. Concordant ST-segment elevation of at least 3 mm in at least two leads C. Concordant ST-segment depression of at least 3 mm in leads V1, V2, or V3 D. Concordant ST-segment depression of at least 4 mm in leads V1, V2, or V3 E. Excessively discordant ST-segment elevation of 2 mm when the QRS result is negative

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Question 3 A 23-year-old male has been brought to the emergency department following a jump off a high wall. He is complaining of pain in his right calcaneum. When assessing the plain radiograph of the calcaneum, what is the normal Böhler’s angle? A. 0–5° B. 20–40° C. 60–100° D. 120–140° E. 140–160°

Question 4 A patient presents with right arm weakness and a Glasgow Coma Scale (GCS) of 13/15. Computerised tomography (CT) of the patient’s head shows an acute subarachnoid haemorrhage; you proceed to perform a CT angiogram, which demonstrates an aneurysm. You are referring to the neurosurgical team. According to the World Federation of Neurosurgical Societies (WFNS) grading scale, what is the grade of this aneurysmal subarachnoid haemorrhage? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4 E. Grade 5

Question 5 You are seeing a 28-year-old male who has quadriplegia from a spinal cord injury at the level of C4. He attends unwell with headache, sweating above the level of the injury and facial flushing. He is hypertensive on examination at 190/105. What is the likely underlying cause? A. Urinary retention B. Spinal shock C. Pheochromocytoma D. Neurogenic shock E. Renal failure

Question 6 You have been asked by management to improve the provision of care to patients with femoral neck fractures. You wish to commence a quality improvement

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project. In order to assess the current situation, you undertake an initial analysis of the problem. Which analysis tool maps impact against difficulty? A. Priority matrix B. Pareto diagram C. Ishikawa diagram D. Root cause analysis E. Process map

Question 7 You are critically appraising a paper looking at the effect of tranexamic acid on patient outcome following traumatic brain injury. The results are presented with p-values. At what p-value is the result statistically significant? A. 6.5 mmol/L) • Elimination of certain poisonings (e.g., toxic alcohols, lithium) – not cyanide • Refractory metabolic acidosis (pH 4. It comprises the following: • Clinical signs and symptoms of deep vein thrombosis (3 points) • An alternative diagnosis that is less likely than PE (3 points) • A pulse rate >100 bpm (1.5 points) • Immobilisation or surgery in the previous 4 weeks (1.5 points) • Previous deep venous thrombosis/PE (1.5 points) • Haemoptysis (1 point) • Malignancy (on treatment, treated in the past 6 months, or palliative) (1 point) Wolf, S. J., McCubbin, T. R., Feldhaus, K. M., Faragher, J. P., and Adcock, D. M. (2004). Prospective Validation of Wells Criteria in the Evaluation of Patients with Suspected Pulmonary Embolism. Annals of Emergency Medicine, 44(5), 503–10.

Question 10 C. 20 J According to the Resuscitation Council UK algorithm ‘Paediatric Cardiac Arrythmias’, decompensated ventricular tachycardia should be treated with immediate synchronised cardioversion. The initial shock should be at 1 J/kg and the second shock at 2 J/kg (with consideration of up to 4 J/kg). A six-year-old child weighing 20 kg should receive an initial cardioversion shock of 20 J. Resuscitation Council UK. European Paediatric Advanced Life Support. 5th edition. May 2021.

Question 11 B. A pyloric mass is pathognomonic for the condition Projectile non-bilious vomiting in a three-week-old is probably due to pyloric stenosis. This condition affects males more than females, and there may be clustering in families. An olive-like pyloric mass palpated in the upper abdomen

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is pathognomonic for the condition. On ultrasonography, a pyloric muscle thickness of >4 mm and pyloric length of >16 mm has a diagnostic sensitivity and specificity of 89% and 100%, respectively. There may be a paradoxical finding of acidic urine in the presence of alkalaemia. Dinkevich, E., and Ozuah, P. O. (2000). Pyloric Stenosis. Pediatrics in Review, 21(7), 249–50.

Question 12 B. Obidoxime can be used as an alternative to pralidoxime An organophosphate overdose following the ingestion of insecticide results in toxic effects due to acetylcholinesterase inhibition. Toxbase states that patients with clinically significant features on presentation (e.g., hypoxia, bradycardia or hypotension) require oxygen and atropine before they are decontaminated as this may be life-saving. If a patient develops signs of acetylcholinesterase inhibition (e.g., secretions, rhinorrhea or bronchoorhea), atropine should be administered, and repeated doses should be given until secretions are minimal and the patient is atropinised. Full atropinisation is established when the heart rate is >80 bpm, the lungs are clear and the blood pressure (BP) is adequate. Pupil size should not be used as an end-point for atropinisation as the pupils may remain constricted for many days. If an atropine infusion is commenced, a starting rate should be 20%/hour of total bolus dose needed for full atropinisation. In the event of cardiac arrest, cardiopulmonary resuscitation should be continued for at least 1 hour. Toxbase. Organophosphorus Insecticides (Organophosphates). March 2016, www.toxbase.org/Poisons-Index-A-Z/O-Products/Organophosphates/ (accessed 27 March 2021).

Question 13

A. Babbles – orientated The paediatric Glasgow Coma Scale (GCS) verbal component equates to the adult GCS as follows: • Oriented – coos/babbles (5 points) • Confused – irritable/cries (4 points) • Inappropriate words – cries to pain (3 points) • Incomprehensible sounds – moans (2 points) • None – none (1 point) Borgialli, D. A., Mahajan, P., Hoyle, J. D., et al. (2016). Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children with Blunt Head Trauma. Academic Emergency Medicine, 23(8), 878–84.

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Question 14 B. Amiodarone Epididymo-orchitis may be caused by amiodarone. If this is the likely cause, the dose should be lowered or stopped. The other drugs in the question are not known to cause epididyo-orchitis. National Institute for Health and Care Excellence (NICE). Scenario: Epididymo-orchitis. September 2020, https://cks.nice.org.uk/topics/scrotalpain-swelling/management/epididymo-orchitis/ (accessed 27 March 2021).

Question 15 B. ≥30 mm

An abdominal aorta is aneurysmal if the diameter is ≥30 mm. Evangelista, A. (2014). Imaging Aortic Aneurysmal Disease. Heart, 100(12), 909–15.

Question 16 D. A shift When analysing the data points on a run chart, the following rules apply: • A shift is when 6 or more data points are above or below the median line; this probably demonstrates an intervention has resulted in change • A trend is when 5 or more data points ascend or descend • An astronomical point is a special case variation when a data point is grossly different from the other data points • Assuming sufficient data points are plotted, the median line should be crossed multiple times. A run is when a series of data points remain above or below the median line Royal College of Emergency Medicine (RCEM). Quality Improvement Guide: A Practical Guide for Clinicians Undertaking Quality Improvement in Emergency Departments. June 2020, https://rcem.ac.uk/wp-content/uploa ds/2021/10/RCEM_Quality_Improvement_Guide_June_2020v2.pdf (accessed 29 March 2022).

Question 17 D. 1.0 A receiver operating characteristic (ROC) curve plots the ‘sensitivity of a test’ against ‘1 minus specificity of a test’. It provides a graphical

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representation of the trade-off between the sensitivity and the specificity of a test, allowing a decision to be made about the optimal positive/ negative cut-off for a test. The greater the area under the ROC curve, the more useful the test. An area under the curve of 0.5 is useless as it means that the test is no better than chance. An area under the curve of 1.0 has perfect discriminatory ability. Hoo, Z. H., Candlish, J., and Teare, D. (2017). What is an ROC curve? Emergency Medicine Journal, 34(6), 357–9.

Question 18 B. Parainfluenza virus Croup is a common cause of upper respiratory inflammation in children characterised by a seal-like barking cough. It usually presents between the ages of six months and six years. The most common viral cause is parainfluenza virus. Bronchiolitis is commonly caused by respiratory syncytial virus (RSV). It can also be caused by adenovirus and rhinovirus. BMJ Best Practice. Croup. March 2021, https://bestpractice.bmj.com/topics/ en-gb/681 (accessed 30 April 2021).

Question 19 D. Body stuffers should undergo a period of observation RCEM has issued guidance on the management of patients who are suspected internal drug traffickers (SIDTs). There are three broad categories: body packers or ‘mules’ (who swallow a number of well wrapped packages in order to smuggle drugs); body stuffers (who ingest small amounts of poorly wrapped drugs to avoid detection); and pushers (who conceal drugs/objects in containers and insert them in to their vagina or rectum). The investigation of choice in patients who are suspected of internal drug trafficking is a low-dose computerised tomography scan (LDCT) of the abdomen and pelvis, not a plain radiograph. A body packer may be discharged to the police/border force if he/she is asymptomatic, where they can be observed in a specialised suite. Body stuffers and pushers should be observed for the effects of the drugs for 8 hours from ingestion if they are asymptomatic, a longer period will be needed if they have symptoms. Urine toxicology should not be used to guide management as there is a high risk of false positives and negatives. Drug packages are forensic evidence and should not be handled or disposed of by hospital staff. This is to preserve the chain of evidence.

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RCEM. Best Practice Guideline: Management of Suspected Internal Drug Trafficker (SIDT). December 2020, https://rcem.ac.uk/wp-content/upload s/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_Decem ber_2020.pdfCOMP: (accessed 29 March 2022).

Question 20 D. 26 mm A Point-of-care ultrasound can be used to assess a patient’s hydration status by assessing the inferior vena cava (IVC) diameter. In an adult, if the IVC diameter is 25 mm with minimal vessel collapse. RCEM Learning. Ultrasound in Emergency Medicine – Level 1 Instruction. www .rcemlearning.co.uk/reference/ultrasound-in-emergency-medicine-level-1-i nstruction/#1571742950803-4f503cab-028a (accessed 29 March 2022).

Question 21 A. QTC = QT/√RR The QTc interval on an ECG can be calculated using the Bazett formula: QTC ¼ QT=√RR QTc is prolonged if >460 ms in women or >440 ms in men. A QTc >500 ms is associated with an increased risk of torsades de pointes. Burns, E., and Buttner, R. (2021). QT Interval. Life in the Fast Line, https://litfl .com/qt-interval-ecg-library/ (accessed 27 March 2021).

Question 22 A. Abdominal swelling When differentiating a histamine-mediated from a bradykinin-mediated allergic response, the clinical features may help. Histamine-mediated reactions (i.e., anaphylaxis) may present with urticaria, itching, a rapid onset, response to adrenaline, hypotension and a wheeze. A bradykinin-mediated response (i.e., angioedema) may include abdominal swelling, peripheral swelling and genitourinary swelling. Swelling of lips/tongue, laryngeal swelling, nausea/vomiting, facial swelling and abdominal pain may be present in both. Bernstein, J. A., Cremonesi, P., Hoffmann, T. K., and Hollingsworth, J. (2017). Angioedema in the Emergency Department: A Practical Guide to

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Differential Diagnosis and Management. International Journal of Emergency Medicine, 10(1), 15.

Question 23

D. After 1 week of the rash, desquamation may appear on the fingers and toes Scarlet fever is an infection caused by strains of Streptococcus pyogenes. Following non-specific viral symptoms, after 12–48 hours, a generalised, red pinhead rash develops. It typically first appears on the chest and stomach before spreading to other parts of the body, giving the skin a sandpaper-like texture. The rash is often accentuated in flexor surfaces, not extensor surfaces. After 1 week, desquamation may appear on the fingers and toes. Patients may develop a white coating on the tongue that peels, leaving it looking red and swollen and giving it an appearance of a ‘strawberry tongue’. Drug and Therapeutics Bulletin. (2018). Managing Scarlet Fever. British Medical Journal, 362(8165), k3005.

Question 24 C. Immobility According to NICE, a comprehensive geriatric assessment should be conducted if the patient has one or more of the following: • Falls • Immobility • Delirium and dementia • Polypharmacy • Incontinence • Is on end-of-life care NICE. Transition between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Needs. December 2016, www.nice.org.uk/guidance/QS136/chapter/Quality-statement-2-Compre hensive-geriatric-assessment (accessed 27 March 2021).

Question 25 B. 301 mosmol/kg Serum osmolality (measured in mosmol/kg) can be calculated by using the following formula: ð2 × Naþ Þ þ glucose þ urea ðall measured in mmol=LÞ

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The Joint British Diabetes Societies Inpatient Care Group recommends this formula for the best approximation of osmolality; however, there are others that include the addition of the potassium level. In this case (2 × 131) + 32 + 7 = 301 mosmol/kg A normal serum osmolality in adults is 275–295 mosmol/kg. In hyperglycaemic hyperosmolar state (HHS) the osmolality is usually ≥320 mosmol/kg – so this patient is not in HHS. Joint British Diabetes Societies Inpatient Care Group. The Management of the Hyperosmolar Hyperglycaemic State (HHS) in Adults with Diabetes. August 2012, https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/di abetes-storage/migration/pdf/JBDS-IP-HHS-Adults.pdf (accessed 27 March 2021).

Question 26 A. Thyroglossal cyst When assessing a child with a neck lump, a thyroglossal cyst is midline and moves with tongue protrusion, a branchial cyst is in the anterior triangle and proximal to the sternocleidomastoid muscle, and a dermoid/epidermoid cyst is midline and moves with overlying skin. A goitre is palpable in the midline and moves upwards with swallowing. Reynolds, S., Yap, D., Marikar, D., and Roland, D. (2020). Fifteen-Minute Consultation: The Infant with a Neck Lump. Archives of Disease in Childhood: Education and Practice Edition, 105(5), 258–61.

Question 27 A. Abdominal pain and vomiting According to Toxbase, following a snake bite, the indications for antivenom are: • Early anaphylaxis-like reactions to the venom • Hypotension persisting for more than 10 minutes, with or without features of shock • Systemic features including abdominal pain and vomiting • Definite leucocytosis (especially if over 20 × 109/L) • ECG abnormalities (bradycardia and widespread ischaemic changes) • Metabolic acidosis • Elevated creatine kinase • Marked local envenoming (e.g., swelling beyond the next major joint from bite site), even in the absence of systemic signs

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• Any other evidence of systemic envenomation (e.g., pulmonary oedema or spontaneous bleeding) Toxbase. Snake Bite – Native British Species. www.toxbase.org/General-Info/Sn akes-index/Snake-Bite—Native-British-Species/ (accessed 27 March 2021).

Question 28 C. Auditory disturbance The Clinical Institute Withdrawal Assessment Scale for Alcohol–Revised protocol (CIWA-Ar) score uses the following parameters to assess severity of alcohol withdrawal: • Nausea and vomiting • Visual disturbance • Paroxysmal sweats • Tactile disturbances • Agitation • Headache, fullness in head • Auditory disturbance • Anxiety • Orientation and clouding of sensorium • Tremor The Clinical Opiate Withdrawal Scale (COWS) can be used to assess the severity of opiate withdrawal. It uses the following parameters: • Resting pulse rate • Sweating • Restlessness • Pupil size • Bone or joint aches • Runny nose or tearing • Gastrointestinal upset • Tremor • Yawning • Anxiety or irritability • Gooseflesh skin Reoux, J. P., and Miller, K. (2000). Routine Hospital Alcohol Detoxification Practice Compared to Symptom Triggered Management with an Objective Withdrawal Scale (CIWA-Ar). American Journal on Addictions, 9(2), 135–44.

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Wesson, D. R., and Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs, 35(2), 253–9.

Question 29 D. This area is governed by law under the Female Genital Mutilation Act 2003 RCEM has issued guidance on female genital mutilation (FGM). Clinicians are not required to ask all female patients with gynaecological presentations if they have undergone FGM. However, if a patient discloses it and is under the age of 18, the police must be informed. Females over the age of 18 who have undergone FGM do not need to be referred to social services or the police. They should be supported and offered relevant follow-up, should they want it. If a patient presents with FGM, clinicians should aim to identify those in their immediate family who may be at risk. The Female Genital Mutilation Act 2003 sets out the relevant law. RCEM. Best Practice Guideline: A Universal FGM Flowchart and Reporting Tool. June 2017, https://rcem.ac.uk/wp-content/uploads/2021/10/FGM_ BP-Guide_Jul2017.pdf (accessed 27 March 2021).

Question 30 B. Viridans group streptococci The likely diagnosis is neutropenic sepsis due to a neutrophil count of ≤0.5 × 109/L in a patient with a fever and systemic upset undergoing chemotherapy. Common Gram-positive bacterial causes are Staphylococcus aureus, Enterococcus species, Viridans group streptococci, Streptococcus pneumoniae, S. pyogenes and Coagulase-negative staphylococci. Common Gram-negative bacterial causes are Klebsiella species, Enterobacter species, Pseudomonas aeruginosa and Escherichia coli. Littlewood, T. J., Clarke, R. T., Jenyon, T., van Hamel Parsons, V., and King, A. J. (2013). Neutropenic Sepsis: Management and Complications. Clinical Medicine, 13(2), 185–7.

Question 31 B. Urgent cases should be reported by phone within 24 hours In England, Public Health England (PHE) should be informed if a clinician encounters a notifiable disease or any infection/contamination (e.g., radiological or chemical) that could cause significant harm to human health. PHE lists all notifiable diseases and classifies them according to urgent or routine notification. All urgent cases should be reported within 24 hours by phone and routine cases should be notified in writing within 3 days. Typhus can be reported routinely and hepatitis A should be reported urgently.

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PHE. Statutory Notification by Registered Medical Practitioners of All Hazards: Infections, Chemicals & Radiation, https://assets.publishing.service.gov.uk /government/uploads/system/uploads/attachment_data/file/820133/PHE_ Notifiable_diseases_poster_HPT.pdf (accessed 27 March 2021).

Question 32 B. Greater auricular nerve There are three nerves that can be blocked to provide regional anaesthesia to the ear: • The greater auricular nerve supplies the inferior part of the ear (i.e., the earlobe) • The lesser occipital nerve supplies the posterior part of the ear • The auriculotemporal nerve supplies the anterior and superior part of the ear Oxford Handbook of Emergency Medicine. 5th edition. August 2020.

Question 33 E. Suspected infection in another baby in the case of a multiple pregnancy NICE states the risk factors for early-onset neonatal infection are: • Invasive group B streptococcal infection in a previous baby • Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy • Prelabour rupture of membranes • Preterm birth following spontaneous labour (before 37 weeks’ gestation) • Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth • Intrapartum fever of >38°C, or confirmed or suspected chorioamnionitis The following are ‘red flag’ risk factors for early-onset neonatal infection: • Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection at any time during labour, or in the 24-hour periods before and after the birth • Suspected or confirmed infection in another baby in the case of a multiple pregnancy NICE. Neonatal Infection (Early Onset): Antibiotics for Prevention and Treatment. August 2012, www.nice.org.uk/guidance/cg149/chapter/1-gui dance#risk-factors-for-infection-and-clinical-indicators-of-possible-infec tion-2 (accessed 27 March 2021).

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Question 34 B. Female sex The CHA2DS2VASc score is endorsed by NICE to predict risk of stroke in the presence of atrial fibrillation. The higher the score, the higher the risk of a thromboembolic event. It comprises: • Congestive cardiac failure (1 point) • Hypertension (1 point) • Age 65–74 (1 point), 75 or older (2 points) • Presence of diabetes (1 point) • History of stroke/transient ischaemic attack (2 points) • History of vascular disease (1 point) • Female sex (1 point) NICE. Scenario: Management of AF. October 2020, https://cks.nice.org.uk/t opics/atrial-fibrillation/management/management-of-af/ (accessed 27 March 2021).

Question 35 D. A recent upper respiratory tract infection The Kocher Criteria can be used to differentiate transient synovitis from septic arthritis in paediatric patients with a painful hip. If any of the four criteria are present, then the possibility of septic arthritis as a cause should be investigated: • Non-weight bearing • A history of fever • A serum white cell count >12 × 10⁹/L • An erythrocyte sedimentation rate of >40 mm/h Kocher, M. S., Mandiga, R., Zurakowski, D., Barnewolt, C., and Kasser, J. R. (2004). Validation of a Clinical Prediction Rule for the Differentiation between Septic Arthritis and Transient Synovitis of the Hip in Children. Journal of Bone and Joint Surgery, 86(8), 1629–35.

Question 36 A. After radiotherapy, symptomatic improvement is often apparent within 72 hours Superior vena cava obstruction may be caused by thrombosis due to intravascular devices or malignant conditions, with non-small-cell lung cancer accounting for ~50% of malignant causes. When recognized, elevation of the

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patient’s head may provide symptomatic relief by reducing hydrostatic pressure. For a malignant cause, radiotherapy may be used and symptoms often improve by 72 hours from initiation of treatment. Over time, development of collateral circulation may improve symptoms. Wilson, L. D., Detterbeck, F. C., and Yahalom, J. (2007). Superior Vena Cava Syndrome with Malignant Causes. New England Journal of Medicine, 356 (18), 1862–9.

Question 37 E. 10–14 days In staphylococcal toxic shock syndrome, desquamation usually occurs 10–14 days after the onset of the illness. It usually affects the palms and soles of the feet. The RCOG advocates the use of the following diagnostic criteria for staphylococcal toxic shock syndrome (four out of five are probable, and all five are diagnostic): • Fever ≥39.9°C • Rash – diffuse macular erythroderma • Desquamation • Hypotension – systolic BP 2/3 the upper limit of normal for serum LDH level Light, R. W. (2002). Pleural Effusion. New England Journal of Medicine, 346(25), 1971–7.

Question 23 E. Coxsackie A16 The clinical case fits with a diagnosis of hand, foot and mouth disease. This is a self-limiting viral illness characterised by vesicles of the oral mucosa and a papulovesicular exanthema of the hands and feet. The most common causative organism is Coxsackie A16. NICE. Hand Foot and Mouth Disease. August 2020, https://cks.nice.org.uk/t opics/hand-foot-mouth-disease/ (accessed 4 April 2021).

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Question 24 E. The consultant paediatrician on-call or the designated SUDI paediatrician should carefully and thoroughly examine the infant once death has been confirmed The Royal College of Pathologists (RCPath) states that after sudden unexpected death in infancy (SUDI) a careful and thorough examination of the infant should be conducted by the consultant paediatrician on-call or the designated SUDI paediatrician; this includes direct fundoscopy for the presence of retinal haemorrhages. If an endotracheal tube has been inserted, this may be removed after confirmation of correct placement and the case has been discussed with the police or coroner. If resuscitation has been attempted, any line inserted for this purpose should only be removed following discussion with the police or coroner. If the family are interviewed, their account should be recorded verbatim, where possible. RCPATH. Sudden Unexpected Death in Infancy and Childhood: Multi-agency Guidelines for Care and Investigation. November 2016, www.rcpath.org/u ploads/assets/874ae50e-c754-4933-995a804e0ef728a4/Sudden-unexpec ted-death-in-infancy-and-childhood-2e.pdf (accessed 27 March 2021).

Question 25 C. The needle should be inserted 2.5 cm proximal to the wrist crease The median nerve is between the flexor carpi radialis tendon and the palmaris longus tendon. The palmaris longus tendon is absent in ~15% of patients. When performing a median nerve block, the needle should be inserted 2.5 cm proximal to the wrist crease. The skin of the lateral 3½ digits and usually the lateral two lumbricals are supplied by the digital branches of the median nerve and the three thenar muscles are supplied by the recurrent branch of the median nerve. World Federation of Societies of Anaesthesiologists. Wrist Block: Landmark Technique. November 2012, www.jcrac.co.uk/tl_files/files/WFSA/WristBlock-Landmark-Technique.pdf (accessed 27 March 2021).

Question 26 B. Gastrointestinal-hepatic dysfunction In patients with biochemical thyrotoxicosis, the Burch-Wartofsky Point Scale (BWPS) can be used to diagnose thyroid storm. It comprises the following factors: • Elevated temperature • Central nervous system effects (e.g., agitation, seizures) • Gastrointestinal-hepatic dysfunction (e.g., diarrhoea, vomiting, jaundice) • Cardiovascular dysfunction (i.e., tachycardia) • Congestive heart failure

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• Atrial fibrillation • Precipitating event Respiratory rate and serum lactate, T3 and T4 levels are not part of the scoring system. Patients who are systemically unwell reduce the ability to convert T4 to T3, so a marginally elevated or normal T3 level, in the context of severe illness, may be considered elevated. Nayak, B., and Burman, K. (2006). Thyrotoxicosis and Thyroid Storm. Endocrinology and Metabolism Clinics of North America, 35(4), 663–86.

Question 27 B. 72 hours Section 5(2) is a section of the Mental Health Act (MHA) that acts as an emergency ‘holding power’ while awaiting MHA assessment. It lasts for 72 hours. It is only to be used in an emergency, when the patient is refusing to stay when all other least restrictive options have been tried and failed. It is only to be used in the inpatient setting, and not in the emergency department. In some NHS trusts the Clinical Decision Unit may count as an inpatient setting. Humphreys, R. A., Lepper, R., and Nicholson, T. R. J. (2014). When and How to Treat Patients Who Refuse Treatment. British Medical Journal, 348(7951), g2043.

Question 28 D. In 20% of cases there is a bilateral slip Slipped upper femoral epiphysis (SUFE) affects adolescents during puberty. It is three times more common in males than females. Obesity and hypogonadism are risk factors for the condition. In 20% of cases both hips are affected. When assessing the plain radiograph of the hip, on the anteroposterior view, if a line is drawn along the superior femoral neck (Klein’s line), it should intersect the femoral epiphysis laterally, if it does not, then there is a slip (this is termed Trethowans’ sign). Once diagnosed, patients should be admitted and put on strict bed rest, and undergo surgical treatment with cannulated screw fixation. Clarke, N. M. P., and Kendrick, T. (2009). Slipped Capital Femoral Epiphysis. British Medical Journal, 339(7731), b4457.

Question 29 A. 1 The CURB-65 severity score can be used to predict 30-day mortality in patients with pneumonia. It comprises five parts with each feature being a predictor of mortality. Each feature is 1 point: with 0–1 being low risk

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(7 mmol/L • Respiratory rate >30/min • Systolic blood pressure 4 hours despite ejaculation and orgasm, and in the absence of continued sexual stimulation. Ischaemic or low-flow priapism is a urological emergency that is characterised by pain. It is treated by aspiration of blood from the corpus cavernosum (not the corpus spongiosum) and/or instillation of phenylephrine. Non-ischaemic priapism or high-flow priapism may be secondary to trauma or neurogenic in nature and is not usually overtly painful. It is uncommon. Treatment may be conservative, depending on the underlying cause. Patients with sickle cell disease may have recurrent, prolonged erections that are usually self-limiting. This is termed ‘stuttering priapism’. BAUS Section of Andrology Genitourethral Surgery, Muneer, A., Brown, G., et al. (2018). BAUS Consensus Document for the Management of Male Genital Emergencies: Priapism. BJU International, 121(6), 835–9.

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Question 35 D. Unfractionated heparin The European Society for Vascular Surgery states that the initial medical management of acute limb ischaemia includes intravenous administration of unfractionated heparin. The initial adult dose is 5,000 iu. This is then followed by an infusion with the rate adjusted to patient response, and monitored by the activated partial thromboplastin time. Intravenous hydration, oxygen and analgesia should also be given. Björck, M., Earnshaw, J. J., Acosta,S., et al. (2020). Editor’s Choice: European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. European Journal of Vascular and Endovascular Surgery, 59(2), 173–218.

Question 36 D. The most common causative organism globally is Enterotoxic Escherichia coli Travellers’ diarrhoea is the term used for the development of diarrhoea three or more times a day when abroad. Globally, the most common causative organism is enterotoxic E. coli. Management is usually supportive. Antibiotic chemoprophylaxis should not be routinely given, unless the patient is at risk of more serious sequalae (e.g., immunosuppressed or pre-existing intestinal disease). If the diarrhoea lasts longer than 2 weeks, it is less likely to be due to a bacterial cause and may be due to protozoa (e.g., Giardia lamblia). The duration of illness may be reduced with a short course of antibiotics. Patients on proton-pump inhibitors are at an increased risk of acquiring Travellers’ diarrhoea. Barrett, J., and Brown, M. (2016). Travellers’ Diarrhoea. British Medical Journal, 353(8054), i1937.

Question 37 B. The most sensitive clinical sign is restriction of internal rotation Perthe’s disease is an idiopathic condition resulting in avascular necrosis of the femoral capital epiphysis. It affects children between the ages of 4 and 12 years, and more commonly affects boys. It is usually unilateral, but can affect both hips in ~15% of cases. Maternal smoking during pregnancy and low birth weight are risk factors for its development. On examination, the most sensitive clinical sign is restriction of internal rotation. Diagnosis is by plain radiography and management based on activity modification, with osteotomy of the femur reserved for older patients and more advanced disease.

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Kannu, P., and Howard, A. (2014). Perthes’ Disease. British Medical Journal, 349(7977), g5584.

Question 38 D. Availability heuristic Cognitive bias is regarded as a potential source of medical error. Knowledge of these potential biases allows clinicians to develop strategies to mitigate against them. Availability heuristic is at play in this question. A diagnosis of aortic dissection is rare, and may be unlikely in this situation; however, it is fresh in the doctor’s mind. Availability heuristic occurs when one recalls information readily at hand and applies it to a situation, sometimes incorrectly. Commission bias occurs when there is a tendency towards action, when in certain situations inaction may be more appropriate (e.g., a small, asymptomatic pneumothorax may only need conservative measures, and not an invasive procedure). Confirmation bias occurs when the clinician looks for evidence to support his/her diagnosis, and tends to ignore evidence that refutes it. An example of this would be attributing abdominal pain in an elderly patient to a urinary tract infection on the basis of weak urinalysis findings, without considering other serious pathology. Base rate neglect describes a situation where a clinician ignores the true prevalence of a condition (e.g., always actively trying to rule out the ‘worst case’ diagnosis even when it is rare). Diagnostic momentum is when a clinician simply agrees with a diagnosis previously made without questioning it. An example would be if a paramedic diagnoses pericarditis, and the treating clinician in the emergency department treats for pericarditis without re-evaluating the patient, when the electrocardiogram demonstrates acute coronary syndrome. O’Sullivan, E. D., and Schofield, S. J. (2018). Cognitive Bias in Clinical Medicine. Journal of the Royal College of Physicians of Edinburgh, 48(3), 225–32.

Question 39 C. 1 year According to the UK immunisation schedule, immunisation against Haemophilus influenzae type b (Hib) is completed by 1 year of age. There are four vaccinations: at 8 weeks, 12 weeks, 16 weeks (as part of the DTaP/IPV/ Hib/HepB combined vaccine) and at 1 year old (as part of the Hib/MenC vaccine).

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GOV.UK. Complete Routine Immunisation Schedule. www.gov.uk/govern ment/publications/the-complete-routine-immunisation-schedule (accessed 10 May 2021).

Question 40 B. Monteggia There are three main eponymous fracture-dislocations of the forearm. A Monteggia pattern is a fracture of the proximal third of the ulna and dislocation of the radial head. A Galeazzi pattern is a fracture of the distal third of the radius with dislocation of the distal radioulnar joint, and an EssexLopresti pattern is a fracture of the radial head with dislocation of the distal radioulnar joint and disruption of the interosseous membrane. A Maisonneuve fracture is a spiral fracture of the proximal fibula and disruption of the distal tibiofibular syndesmosis and interosseous membrane. A Segond fracture is an avulsion fracture from the lateral tibial plateau of the knee, often associated with anterior cruciate and lateral collateral ligament damage. Desai, A., Amer, M., Tourret, L., and Phadnis, J. (2019). Forearm Fracture Dislocations. Orthopaedics and Trauma, 33(5), 330–40.

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Index

(p)RIFLE, acute kidney injury, 52 abbreviated mental test score (AMTS), 123, 137 abdominal aorta, aneurysmal, 65, 79 abdominal mass, 94, 119–20 on examination, 108 abdominal pain a 40-year-old female with, 130 a 9-month-old boy with, 102 intussusception and, 119–20 abdominal swelling, 81 acanthamoeba, 72, 88 accessory muscles, use of, 105–6 acetylcholinesterase inhibition, 78 acetylcysteine, intravenous, 11 Aciclovir, treatment for chickenpox in pregnancy, 74 acidosis metabolic, 45 acrocyanosis, 33 activated partial thromboplastin time (APTT), 97, 112 acute appendicitis, Alvarado score for, 93, 107 acute conjunctivitis, 5 acute coronary syndrome diagnosis of, 3–4 acute kidney injury, 6, 21, 63 diagnoses of acute, 52 diagnostic criteria for, 36 guidance on acute, 52 renal replacement therapy, 76 acute limb ischaemia, 93, 131 medical management of, 147 acute liver failure, 11 and paracetamol overdose, 25 acute mountain sickness (AMS), 55

acute myocardial infarction, Sgarbossa criteria for, 14 acute pericarditis, 56 management of, 39 acute respiratory distress syndrome (ARDS), 123, 137 acyclovir, oral, 45–6 adenovirus, 66, 99 adjuvant chemotherapy, breast cancer and, 70 adrenal crisis laboratory abnormality in, 124 laboratory findings in, 137 adrenal tumours, incidental, 24 adrenaline infusion, 23 adrenaline infusion, when to start intravenous, 23 advance decision, 51 advance decision, the requirement for validity of, 35 Advanced Life Support algorithm, 24 Aerobic Gram-negative organisms, 42 age BRUE (brief resolved unexplained event) and, 54 gallstones and, 130 airway assessing the, 8 AKIN, acute kidney injury, 52 alcohol alcoholic female and withdrawal, 69 alcoholics with acute severe abdominal pain, 37 liver disease, 99 withdrawal from, 69 alcoholic liver disease. See liver disease Alert, Verbal, Pain, Unresponsive (AVPU) score, 121

150

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Index alleged sexual assault, 5 allergic response, 81 alteplase, 131 Alvarado score system, for diagnosing acute appendicitis, 93, 107 alveolar–arterial (A-a) gradient, 130, 145 American College of Rheumatology, 49 American Heart Association, 26 amiodarone, 79 amnesia, transient global, 48 amyl nitrate (poppers), 130 anaemia, 6 haemolytic, 21, 121, 125, 134–5, 139 normochromic, 124, 138 anaesthesia local, 19 regional, 86 anaesthetic block, regional, 128 anaesthetic toxicity, local, 62 analysis tool maps, femoral neck fractures and, 3 anaphylaxis, 23, 81 after intravenous flucloxacillin, 9 dosing of intramuscular (IM) adrenaline in, 14 aneurysm, 2 aneurysmal subarachnoid haemorrhage, 2 grading scale for, 15 angiogram, CT, 2 anion gap, 93 calculating, 106 ankle-brachial pressure index (ABPI), 93 and peripheral vascular disease assessment, 108 anorexia nervosa, 35 Sit-Up, Squat-Stand (SUSS) test and, 51 antepartum haemorrhage, 116 anterior cruciate, 149 anterior uveitis, 19 diagnosis of, 5 antibiotic drugs, 9, 58, 124 ampicillin-based, 138 to be avoided, 9

antimicrobial therapy, 42 antivenom, snakebite and, 69, 83–4 aortic dissection, 132 diagnosis of, 148 APGAR score, 33, 47–8 aplastic anaemia, 26 drugs to be used for, 11 appendicitis Alvarado score for acute, 107 male and female ratio of, 108 appendicitis, diagnosing, 93 arterial blood gas (ABG), 92–3 arthritis rheumatoid, 122 artificial pacemaker function, letter coding of, 123 ascites, 99 aspirin, 131 Association of Anaesthetists of Great Britain and Ireland Safety guideline, 75 asthma, category of acute severe, 92 asystole, 109 increased risk of, 94 prolonged, 128 atraumatic cardiac arrest, 3 atrial fibrillation male with palpitations, 40 risk of stroke after, 71, 87 auditory disturbance, 84–5 auditory hallucinations, 63 auricular nerve, 86 greater, 86 auriculotemporal nerve, 86 autonomic dysreflexia, 15–16 availability heuristic, 132, 148 avulsion fracture, 149 base rate neglect, 148 Bazett formula, 81 bias cognitive, 132, 148 commission, 132 confirmation, 132, 148 bilateral wheeze, 36–7

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biliary colic, 130 Blatchford Bleeding Score, 96 nonvariceal upper gastrointestinal bleed and, 111–12 blood transfusion, 131 products, 46 requirement for, 146 body packers/stuffers, 66, 80–1 Böhler’s angle, 2 normal, 15 bolus, 75 bone metastases, 62 bowel obstruction, 22 bradykinin-mediated pathophysiology, 67 bradykinin-mediated response, 81 branchial cyst, 69, 83 breast cancer adjuvant chemotherapy for, 70 metastatic, 62 bright red rash, cause of, 29 British Association for Sexual Health and HIV UK guideline, 26 British Geriatrics Society, abbreviated mental test score (AMTS), 137 British Pacing and Electrophysiology Group (BPEG) coding system, 136 British Society for Paediatric Endocrinology and Diabetes, 45 bronchiolitis, 80, 115 a 5-month-old child with, 99 child with, 52 National Institute for Health and Care Excellence (NICE) guidelines for, 52 risk factors for severe, 52 viral cause of in a child, 99 BRUE (brief resolved unexplained event), 37–8, 54 Burch-Wartofsky Point Scale (BWPS), 129, 143–4 burns measuring thickness of, 104 skin, 138 thermal, 40

caesarean section perimortem, 127, 142 calcaneum, 2 radiograph of the, 15 calcium gluconate gel, 138 Caldicott Principles, 99, 114 campylobacter jejuni, 6 Canadian Study of Health and Ageing (CSHA), Clinical Frailty Scale, 43 cancer breast, 62, 70 lung, 61 non-small cell, 87 small-cell lung, 71 throat, 30 treatment, 49, 55 cannulated screw fixation, 144 carbon monoxide poisoning, 121, 134–5 carboxyhaemoglobin (COHb) concentration, 134–5 cardiac arrest, 7, 64 4-week-old child in, 128 due to hypothermia, 24 duration of, 54 guidelines on, 54 hypothermic, 21 management of severe local anaesthetic toxicity in, 75 perimortem caesarean section and, 127 traumatic least favourable prognostic sign and, 38 cardiac death, sudden, 67 cardioversion of a child, 64 synchronised, 64 synchronised DC, 77 carotid artery, 111 cauda equina syndrome, 13 cellulitis, 8 gangrenous, 42 orbital, 122 preseptal, 75 preseptal vs postseptal, 61, 75 Centor scoring system, 124, 138

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Index cerebral oedema, high-altitude, 55–6 cerebrospinal fluid (CSF) opening pressure, 28 cervical radiculopathy, motor innervation of C7 and, 122 cervical roots, motor innervation of the, 135 CHA2DS2VASc score, 87 stroke risk assessment and, 71 chelation therapy, 22 chemical, biological, radiological and nuclear (CBRN) policy, 101 chemoprophylaxis, antibiotic, 132, 147 chest auscultation and bilateral wheeze, 36–7 chest injury, 35 chest pain, 132 pleuritic, 63 chest wall retractions, 73, 89 chickenpox managing with a pregnant woman, 61, 74 child. See children childbearing age, women of, 142 children acute kidney injuries in young people and, 52 cardioversion shock of, 77 computerised tomography (CT) scan after head injury, 106–7 diagnosis of nephrotic syndrome in, 105 eGFR in young people and, 52 intravenous fluid rates for young people and, 27 limping, 132 management of pain in, 101, 118 painful hip of, 71 projectile, non-bilious vomiting, 64 restricted use of codeine by, 118 systemic vasculitis affecting, 118 use of ketamine sedation in, 105 Chlamydia pneumoniae, 41, 59 Chlamydia trachomatis, 125 treatment of, 139

153

chlorate poisoning, 131, 146 cholangitis, ascending, 130 clarithromycin, 24 clinical decision unit (CDU), 144 Clinical Institute Withdrawal Assessment Scale for AlcoholRevised protocol (CIWA-Ar) score, 69, 84–5 Clopidogrel, 132 clostridium difficile, 6 Coagulase-negative staphylococci, 85 codeine, 91 children and, 101 converting to oral morphine, 104 restricted use of, 118 cognitive bias, 132, 148 Colchicine, 56 colchicine toxicity increased risk of, 98, 114 medication and risk of, 98 colic, biliary, 130 collateral ligament damage, 149 colloid cyst, 48 commission bias, 148 compartment syndrome abdominal, 40, 58 of the leg, 122 suspected, 35, 50 complex tachycardia, broad, 64 compression ultrasonography, for diagnosis of thrombosis, 23 computerised tomography (CT) scan, 2, 10, 93, 140 for children with head injuries, 106–7 of body packers, 80 computerised tomography (CT)scan of the brain, 28 computerised tomography pulmonary angiogram (CTPA), 63 concordant ST-segment depression, 1, 14 concordant ST-segment elevation, 1, 14 confidential information, use of patients, 114

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confirmation bias, 148 conjunctivitis, acute infective, 19 consciousness, transient loss of, 126 contact lens wearers, 88 cord clamping, delayed, 146 vs immediate, 131 core temperature, 21 and shock withdrawal, 7 corneal abrasion, 56 corpus cavernosum, 146 coryzal illness, 36–7 symptoms of, 29, 127 cough diagnosis of pertussis and, 119 recurrent, 102 cough syncope, driving and, 48 COVID-19, diagnosis of, 98 worsening respiratory symptoms, 123 COWS Score for Opiate Withdrawal, 84 Coxsackie A 16, 30, 42, 128, 142 croup, 80 assessing the severity of, 72, 89 viral cause of, 66 cryptosporidiosis, 125, 140 CT angiogram, 2 CURB-65 score, 130, 144–5 cyanide antidote for poisoning from, 37 elimination of, 76–7 severe poisoning, 53 cyanosis, 54, 89, 102, 119, 130 cyanotic state, centrally, 130 cytomegalovirus, 66 dapsone poisoning, 131, 146 data points, analysing the, 65, 79 D-dimer test, 63 decompression sickness protection against risk of, 10–11 risk of, 25 deep vein thrombosis (DVT), 77 Wells score for, 38, 55

defibrillation energy for, 16–17 energy for 1-year-old, 17 degloving injuries/wound, 122, 135 patterns of, 135 dementia, elderly patient with suspected, 123 dermatomyositis, 122, 136 dermoid cyst, 69 desferrioxamine, 22 desquamation, 72 detumescence, 131 dexamethasone, steroid therapy with, 137 diabetes, 24, 57, 87 children diagnosed with diabetic ketoacidosis (DKA), 45 type 2, 39, 68 diabetic ketoacidosis (DKA) children diagnosed with, 45 diabetic patient 62-year-old man, 9 hyperosmolar hyperglycaemic state (HHS) of the, 57 diagnostic momentum, 132 diagnostic tests, sensitivity measures of, 17 diamorphine, intra-nasal, 118 diarrhoea, 132 causative organism of diarrhoeal illnesses, 6, 21 chronic, 132 Travellers’, 132, 147 dicobalt edetate, for severe cyanide poisoning, 53 distal radioulnar joint, dislocation of the, 149 distal radius, fracture of the, 4 doxycycline, 139 Driver and Vehicle Licensing Agency (DVLA) cough syncope and, 48 guidelines, 33 drowning management of victims, 31 risk of, 45 dry decontamination, 101, 118

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Index ear blocking nerves to for regional anaesthesia, 86 local anaesthesia for earlobe wound closure on, 70 early-onset neonatal infection, risk factors for, 70, 86–7 East Africa, returned from, 132 eclamptic seizure, 49 eGFR, in children and young people, 52 elbow extensors, 135 elbow flexors, 135 electrocardiogram (ECG), 1, 9 acute coronary syndrome and, 148 pulmonary embolism and, 21 QT interval on an, 76 QTc interval on an, 81 results of, 40 syncopal episode and, 67 electromyography, abnormal, 136 emergency contraception, 41 Levonorgestrel as, 58–9 emergency physician in charge (EPIC), 7, 9 enterobacter species, 70, 85 enterococcus faecalis, 99, 115 enterococcus species, 85 enterocolitis, necrotising, 131 Enterotoxic Escherichia coli (ETEC), 132, 147 Entonox®, 118 safe use of, 35 when to avoid use of inhaled, 50 epidermoid cyst, 69 epididymo-orchitis, 79 medication for, 65 epilepsy, 106, 141 and risk of drowning, 31, 45 suspected, 126 epistaxis, 95, 110 erection, 131 erythema, 61 erythema infectiosum, 42 erythema multiforme, 109 erythrocyte sedimentation rate, 49

155

escharotomy, 58 burns and, 40 escherichia coli, 6, 21, 70, 85, 99, 115 Essex-Lopresti fracture, 133, 149 ethmoidal artery, 96 European Pressure Ulcer Advisory Panel (EPUAP), 110 European Society for Vascular Surgery, 147 European Society of Cardiology guidelines, 56 exercise restriction, 56 expectant mother, 4, See also pregnant woman/women knee-chest position and, 18 extensor plantar responses, Guillain– Barré syndrome and, 113 eyes appropriate step in managing pain in the, 100 high pressure at back of, 13 possible cause of pain in, 72 red rash around the, 122 reducing intraocular pressure, 117 sudden pain in right, 100 swelling around his right, 61 facial artery, 96 facial bones, examination after an assault, 126 facial rash, 3-year old boy and, 29 factor VII deficiency, 112 Factor VIII and IX assays, 112 fasciotomy, lower leg, 135 favism, 139 female genital mutilation (FGM), 69, 85 femoral neck fractures, 2 intertrochanteric, 39 ferrous fumarate tablets digestion of, 7 overdose of, 22 fetomaternal haemorrhage, 116 finger abductors and adductors, 135 finger extensors, 122, 135 finger flexors, 135

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finger, pain on active flexion of the, 116 flexor carpi radialis tendon, 143 flexor sheath infection, 116 Kanavel cardinal signs and, 100 flucloxacillin, intravenous, 8 fluid bolus, 126 fluid resuscitation, 11, 89 Parkland formula for, 72 focal neurological deficit, 15 foot dorsiflexors, 28 foot pain, runner and, 126 forensic medicine sexual assault and, 5 fracture-dislocation pattern, 133 fractures, 133 lateral wall, 140 stress, 141 frailty, 68 measurement of, 43 Rockwood clinical frailty scale score, 30 fresh frozen plasma (FFP) transfusion, 32, 46 Galeazzi pattern, 133, 149 gallstones, risk factors for, 130, 145 gangrenous cellulitis, 42 gastrointestinal-hepatic dysfunction, 129 genital herpes management of in pregnancy, 45–6 pregnant woman and, 31–2 geriatric assessment, when to do a comprehensive, 82 gestation, a baby at 30-weeks, 131 giant cell arteritis, diagnosis of, 49 Giardiasis, 125, 140 Glasgow Coma Scale (GCS), 2, 15, 50, 93, 97, 121, 129, 130 head injury in children, 106–7 paediatric verbal response assessment, 65 verbal component, 78 Glasgow criteria, for severe abdominal pain, 37

Glasgow prognostic score, 53 glaucoma, acute, 117 glucose-6-phosphate dehydrogenase (G6PD) deficiency, 125, 131, 139, 146 goitre, 69, 83 gout, 98 Gram-positive infection, 85, 88 Graves’ disease, 62-year-old patient with, 129 Greenbook (Public Health England), 46–7 gross submandibular swelling, 29 Guillain–Barré syndrome (GBS), 98 diagnosis of, 113 haematemesis, management of, 40 haematological indices, 146 haematological malignancy, 42 haematuria, sensitivity of, 52 haemoglobin, peak, 131 haemolytic anaemia, 21, 121, 125, 134–5, 139 haemolytic uraemic syndrome, 21 Haemophilia A or B, 112 haemophilus influenzae, 41 type b (Hib), 133, 148 haemoptysis, 77 haemorrhage aneurysmal subarachnoid, 2 fetomaternal, 116 haemorrhagic shock, 32 intraventricular, 146 retinal, 143 risk of intraventricular, 131 upper gastro-intestinal, 98 halos, 100 hand laceration, 128 head impulse test, 44 head injury, 35 10-month-old, 93 NICE guidelines for, 106–7 headaches, 134 hearing loss, sudden, 10, 25 heart failure, 67

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Index heatstroke classification of, 111 feature of classic (passive), 96 heatwave, 82-year-old male and, 96 heliotrope rash, 136 Henoch–Schönlein purpura (HSP), 102 diagnosis of, 118 heparin, unfractionated, 132, 147 Hepatitis B exposure to, 96 immunoglobulin, 111 vaccination/vaccine, 5, 19, 96, 111 hereditary methaemoglobinaemia, 131 hernias femoral, 7, 21 groin, 7, 21 indirect, 7 inguinal, 7, 22 herpes simplex virus, 94, 109 high-altitude emergencies, 38 hip pain, 13-year-old boy with, 129 histamine-mediated pathophysiology, 67 histamine-mediated reactions, 81 HIV HIV Post-Exposure Prophylaxis following Sexual Exposure (PEPSE), 11, 26 HIV-positive patient, and needlestick injury, 11 test when evaluating PUO, 42 holding power, emergency, 144 Holliday–Segar formula, 27 human chorionic gonadotropin (βHCG) levels, 127, 142 human enzyme defect, 139 human herpes virus 6, 30, 128 human metapneumovirus, 99 hydration status, 81 hydrocortisone, steroid therapy with, 137 hydrofluoric acid dermal exposure to, 138 exposure to, 124 hydroxocobalamin (Cyanokit®), 53 hyperbaric unit, 10

157

hypercalcaemia cases of, 76 feature of, 62 ionised, 32 hypercyanotic episodes, 140 in Tetralogy of Fallot (ToF), 126 hyperemesis gravidarum, the diagnostic requirement for, 124, 139 hyperglycaemia, 124 hyperglycaemic hyperosmolar state (HHS), an elderly lady in, 68 hyperkalaemia, 49, 138 hyperlipidaemia, 91 hypernatraemia, 124 hyperosmolar hyperglycaemic state (HHS), 40 diabetic patient in, 57 hyperparathyroidism, primary, 76 hypertension, 10 idiopathic intracranial, 28 in pregnancy, 49 intra-abdominal, 58 ramipril for, 36 hyperuricaemia, 49 hyphema, traumatic, 56 hypoalbuminaema, 105 hypocalcaemia, 34, 49, 124 hypoglycaemia, 138 hypokalaemia, 34, 124 hyponatraemia, 34, 95, 137 correction sodium level for patient with, 110 hypovolaemic, 95, 110 hypophosphataemia, 34 hyporuricaemia, 34 hypothermia correct statement about, 10 moderate, 24 hypothermic cardiac arrest, 21 hypoxia, 145 hypoxic patient, 130 idiopathic intracranial hypertension, diagnostic criteria for, 28 iliac fossa pain, 93

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158

Index

ill child, recognising, 121 illicit drugs, management of patients concealing, 66, 80–1 immune thrombocytopenia, 112 immunisation, 133 against infectious diseases, 111 immunosuppressant agents, 136 indomethacin, 26 Indonesia, fever and eschar after visiting, 125 infants BRUE and, 37–8 cardiac arrest in, 128 infectious diseases, 46 immunisation against, 111 infective conjunctivitis, acute, 19 inferior vena cava (IVC) diameter, hydration status assessment and, 81 inflammatory pericarditis, diagnosis of acute, 56 infraorbital fat, inferior herniation of, 126 infusion rate, 75 insecticide, ingestion of, 64, 78 intention-to-treat analysis, 114 International Classification of Diseases diagnostic criteria for OCD, 117 interosseous membrane, disruption of the, 149 intracranial pressure, 18, 50 intralipid, 62, 75 intramuscular adrenaline, 9 anaphylaxis and, 23 dose of for a child, 1 intra-ocular pressure, 56 intraventricular haemorrhage, 146 risk of, 131 intubation, difficulty of, 23 intussusception a 9-month-old boy and, 103 ultrasonography as diagnostic tool, 119–20 iron overdose, management of, 7 irregular breathing pattern, 37–8

ischaemia, acute limb, 93, 131 medical management of acute limb, 147 Jadad scoring system, 98, 114 jaundice, mild, 125 Joint British Diabetes Societies Inpatient Care Group, 57, 83 Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC), 46 jugular line, insertion of, 18 junior doctors, how to recognise the ill child, 121 Kanavel cardinal signs, 100, 116 Katayama fever, 125, 140 Kawasaki disease diagnosis criteria for a child, 12 diagnostic criteria for, 26–7 KDIGO, acute kidney injury, 52 keratic precipitates, 19 ketamine sedation, 92 use of in children, 105 ketones, child and, 31 ketonuria, 139 Kidney Disease Improving Global Outcomes (KDIGO), 105 kidney injury. See acute kidney injury King’s College criteria, 25 Klebsiella species, 70, 85, 99, 115 Kleihauer-Betke analysis, 100, 116, 127, 142 Klein’s line, 144 knee extensors, 28 knee-chest position, pregnant women and, 18 Kocher Criteria, 87 lactic acidosis, 37 severe, 53

https://doi.org/10.1017/9781009003834.012 Published online by Cambridge University Press

Index lateral epicondyle in a 9-year old, 48 ossification of, 48 lateral tibial plateau of the knee, 149 left bundle branch block (LBBB), 1 pre-existing, 14 leg wounds closing, 5 surgical intervention for, 32, 46 leg, paraesthesia of his right, 131 lesions, 24 a pregnant 28-year-old female with, 31–2 bullous/vesicular, 26 Large Morel–Lavallée, 122 lipid-rich, 10 malignant, 10 Morel–Lavallée lesions, 122 target, 94, 109 Levonorgestrel, 58–9 Levothyroxine, 114 lidocaine, 19 local anaesthesia, 5 life-sustaining treatment, advanced decision to refuse, 51 Light’s criteria, and pleural fluid protein, 142 Lisfranc injury Lisfranc disruption, 109–10 radiographic assessment of, 94–5 Little’s area/Kiesselbach’s plexus, epistaxis at the, 110 liver failure, acute, 11, 25 local anaesthesia, 70 local anaesthetic toxicity, 62 management of severe, 75 Ludwig’s angina, 42 lung cancer non-small cell, 87 small-cell, 71 syndrome of inappropriate antidiuretic hormone (SIADH) and, 61 lymphadenopathy, cervical, 27

159

macular erythroderma, diffuse, 72 magnetic resonance imaging technique, 142 maintenance fluids, children and, 12 Maisonneuve fracture, 133, 149 Major Incident Management protocols, 35 male patient, analgesic requirements of, 91 Mallampati score, 8, 23 mandibular fractures, 97, 113 mass casualty event, METHANE acronym and, 75 massive transfusion protocol, and haemorrhagic shock, 32 maxillary artery, internal, 110 measles virus, 30, 128 median nerve block for a hand laceration, 128 insertion of the needle, 143 median nerve, location of, 143 mediastinum, 42 Medicines and Healthcare products Regulatory Agency, 118 Meningitis Research Foundation, 18 meningitis, setting sun sign and, 18 meningococcal septicaemia, 4 Mental Capacity Act, 51 Mental Health Act (MHA) and detaining patients for assessment, 76 and Section 2 assessment order, 63 emergency holding power and, 144 metabolic acidosis, 22 8-year old boy and, 31 methaemoglobinaemia, 131 hereditary, 131 methaemoglobinaemia, treatment of, 146 METHANE acronym, 62, 75 methylene blue, 146 Metoprolol, 57 microbial keratitis, 88 middle ear disease, 35

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160

Index

Mobitz type 1 atrioventricular block, 94, 109 type 2 atrioventricular block, 94, 109 Monteggia pattern, 133 of a fracture of the ulna, 149 Morel–Lavallée lesions, 122, 135 Large, 122 mortality, 30-day, 20 motor innervation of L4, for cauda equina syndrome, 13 muscle aches, 9-year-old boy and, 97 muscle power, assessment of, 51 muscle weakness, 136 after COVID-19, 98 of his upper arms, 122 myasthenia gravis, 57 medication for, 40, 124 mycoplasma pneumoniae, 41, 59, 109 National Institute for Clinical and Care Excellence (NICE) emergency contraceptive advice, 58 epilepsy features and, 141 steroid therapy criteria, 137 National Institute for Health and Care Excellence (NICE), 27, 36, 68, 70, 82, 86–7, 93, 108 guidelines for bronchiolitis, 52 guidelines on acute kidney injury, 52 guidelines on hypertension in pregnancy, 49 head injury guidelines, 106–7 Traffic Light system, 121 National Pressure Injury Advisory Panel (NPIAP), 110 National Tracheostomy Safety Project algorithm, 44 nausea and vomiting of pregnancy (NVP), 139 neck burns to the, 40 escharotomy to the, 58 fractures of the, 2, 39, 144 gangrenous cellulitis to the, 42 pain in the, 122

stab to the, 32 zones of, 47 neck lump, tongue protrusion and, 68–9, 83 necrotising enterocoliti, 146 necrotising enterocolitis, 131 necrotising fasciitis, 9, 24 suspected, 9 necrotising mediastinitis, 42 needlestick injury, 11 neglect, base rate, 132 neonates, APGAR score of the, 33, 47–8 nephrotic syndrome diagnosis of in children, 105 diagnostic criteria for, 91 nerve, blocked for local anaesthesia for earlobe wound, 70 nerves, of the ear, 86 neurogenic shock, 15 neurointensive care, intracranial pressure, 18 neutropenic sepsis, 85 newborn life support, 98 Newborn Life Support algorithm, 113 NHS complaints procedures of the, 17 constitution and receiving an acknowledgement from, 4 non-caustic chemical agent, dry decontamination after exposure to, 118 non-Hodgkin lymphoma, 34 non-osmotic ADH secretion, 27 non-small cell lung cancer, 87 non-steroidal anti-inflammatory drugs (NSAIDs), 56 nonvariceal upper gastrointestinal bleed, identifying, 111–12 nonvariceal upper gastrointestinal bleed, suspected, 96 normochromic anaemia, 124, 138 North American Society of Pacing and Electrophysiology (NASPE), 136 notifiable diseases, 70 reporting of, 85–6

https://doi.org/10.1017/9781009003834.012 Published online by Cambridge University Press

Index novel test, 3–4, 66 noxious substance, use of dry decontamination afterexposure to, 101 null hypothesis, 16 nystagmus, vertical, 44 obidoxime, alternative to pralidoxime, 78 obsessive-compulsive disorder (OCD) 8-year-old child with possible, 101 diagnosis of, 101 diagnostic criteria for, 117–18 obstetric help, 18 for umbilical cord prolapse, 4 occipital nerve, lesser, 86 oedema high-altitude cerebral, 55–6 high-altitude emergencies and, 38 periorbital, 91 oesophageal varices, 40 oral codeine, converting to oral morphine, 104 oral fluid intake, inadequate, 52 orbital blowout fracture, 126 orbital cellulitis, 122 organophosphate overdose, 78 osmolality, 82 ossification centre, fusing of for a child, 33 osteoporosis, medication that can cause, 39 oxygen saturation, 6, 20, 37, 52, 73, 113, 123, 137 acceptable level, 98 pacemaker interrogation, 123 paediatric elbow, ossification of, 48 Paediatric Emergency Drug Chart, 16, 19, 115–16 paediatric fluid management, 12 paediatric fractures, 8 paediatric patients, 72, 98, See also children; infant; neonates physical fractures in, 8 suspected croup and, 66

161

paediatric resuscitation area, 4, 64, 72, 98 Paediatric Rheumatology European Society, 118 paediatric triage nurse, 12 paediatric verbal response, Glasgow Coma Score (GCS) assessment and, 65 paediatrician, sudden unexpected death in infancy (SUDI), 128, 143 pain management guidelines, in children, 101 palliative care, 91 palmaris longus tendon, 128, 143 palpable purpura, 118 a child with, 102 palpitations, 129 72-year-old male, 123 a 63-year old male with, 40 prolonged, 123 pancreatitis, 53 gallstones and, 130, 145 Glasgow prognostic score for, 53 pancytopenia, 11 papulovesicular exanthema, 128 paracetamol, 101, 118 feeling unwell after taking, 11 overdose and acute liver failure after taking, 25 overdose from, 11 parainfluenza virus, 66, 99, 115 croup and, 80 Parkland formula, 89 fluid resuscitation, 72 parvovirus B 19, 29, 42, 128 peak haemoglobin, 131 percentage total body surface area (TBSA) of burns, 91 perfect discriminatory test, 66 pericarditis diagnosis of acute inflammatory, 56 management of, 39 management of acute, 56 perimortem caesarean section, 142 cardiac arrest and, 127

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162

Index

periorbital cellulitis. See preseptal cellulitis periorbital oedema, 91 peripheral vascular disease, 108 peritonitis bacterial, 115 spontaneous bacterial, 99 Perthes’ disease, 132, 147 pertussis a 8-month boy and possible, 102 diagnosis of, 119 mandatory diagnosis criteria for, 102 pheochromocytoma, 16 photophobia, 72 physis fractures, 22 Pilocarpine eye drops, 117 placenta praevia, 116 placental abruption, 100, 116 pleural effusion, 127 pleural-fluid protein, 142 pleuritic chest pain, 63 pneumonia 30-day mortality predictions for patients with, 144–5 a 62-year-old male with, 130 polymorphous exanthema, 26 poppers (amyl nitrate), 130 postseptal/orbital cellulitis, 75 pralidoxime, 78 prednisolone, for myasthenia gravis, 124 pregnancy early, 35 management of chickenpox in, 61, 74 managing genital herpes in, 45–6 nausea and vomiting (NVP) in, 139 trauma in, 127 use of Doxycycline in, 139 with vaginal bleeding, 100 pregnant woman/women. See also pregnancy haemolytic anaemia and, 134–5 investigation of suspected pulmonary embolism, 6 management of chickenpox in, 74

moribund, 127, 142 pulmonary embolism and, 21 treatment option for seizure in, 34 with intractable vomiting, 124 preseptal cellulitis vs postseptal cellulitis, diagnosis of, 61 pressure ulcers classification of, 110 Pressure Ulcer Classification System, 110 stage of, 95 preterm infant, cord clamping and, 146 priapism, 131, 146 probability value (p-value), 16 prodromal symptoms, 126 prolonged QTc interval, prescribing antibiotics and, 9 prophylaxis, post exposure, 96 propofol, 62, 75 allergy to, 92 proptosis, absence of, 75 Proteus species, 99, 115 prothrombin time (PT), normal, 112 proximal fibula, fracture of the, 149 pseudomonas species, 72, 88, 99, 115 pseudomonas aeruginosa, 70, 85 psychosis acute, 129 negative, 119 symptoms of negative, 119 Public Health England (PHE), 85, 111 Greenbook, 46 pulmonary embolism (PE) electrocardiogram and, 21 managing as an outpatient, 5–6 pregnant women and, 21 pre-test probability of, 77 Pulmonary Embolism Severity Index (PESI) score, 5–6, 20 pulmonary embolus, 63 pulmonary infiltrates, sickle-cell anaemi and, 41 pulmonary oedema, 55 pyloric mass, pyloric stenosis and, 77–8 pyloric stenosis, 77–8

https://doi.org/10.1017/9781009003834.012 Published online by Cambridge University Press

Index pyrexia, 37, 41, 55 of unknown origin (PUO), 29, 42 QT interval, shortening of the, 76 QTc interval drugs to prolong, 24 on an electrocardiogram (ECG), 81 syncopal episode and, 67 quality improvement project, data points and, 65 radial head, dislocation of the, 149 radiotherapy, improvements after, 87 radius, fracture of the distal third of the, 149 raltegravir, 26 ramipril, for hypertension, 36 randomised control trial (RCT) on the use of tranexamic acid, 98 rash desquamation, 82 receiver operating characteristic (ROC) curve, 66, 79 recombinant factor VIIa, 58 refractory anaphylaxis, treatment for, 23 regional anaesthesia, 86 relative afferent pupillary defect (RAPD), 75 renal calculi, 36 renal failure, 146 concurrent, 131 renal replacement therapy, 76 indication for, 63 respiratory distress, 9, See also acute respiratory distress syndrome (ARDS) a 63-year-old male in, 30 child in, 52 female in, 130 overt, 38 respiratory rate, 123, 130, 145 respiratory syncytial virus (RSV), 66, 80, 99, 115 Resuscitation Council UK, 14, 21, 23 bradycardia algorithm, 109 Newborn Life Support algorithm, 113

163

Paediatric Emergency Drug Chart, 16, 115–16 resuscitation dose, 100 atraumatic cardiac arrest and, 3 retinal haemorrhage, 143 retropharyngeal space, spreading of necrotising mediastinitis through, 42 rhesus D negative women, Kleihauer test and, 116 rheumatic fever criteria for, 97 diagnosis of, 112–13 rheumatoid arthritis, 122 rhinovirus, 66, 99 right atrial pressure, IVC diameter indicating, 67 Rockwood clinical frailty scale score, 30 rotavirus, 6 Royal College of Emergency Medicine, 50, 51, 105 guidance on illicit drugs concealment, 80 guideline on female genital mutilation, 85 guidelines for sexual assault, 19 guidelines on the management of pain in children, 118 guidelines on traumatic cardiac arrest, 54 Royal College of Obstetricians and Gynaecologists, 18, 21, 88, 139 guideline on chickenpox, 74 Royal College of Pathologists SUDI and, 143 Royal College of Psychiatrists, 6, 20 run chart, data points on, 79 salmonella, 6 Salter-Harris grade 4 fractures, 22 sarcomatoid carcinoma, 35 saturations, 113 oxygen, 123 scarlet fever, 82 suspected, 67–8

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Index

schizophrenia a 32-year-old male with, 129 and poor compliance with treatment, 102 family history of, 63 negative symptom of psychotic, 102 scleroderma, 122 sclerotherapy, variceal bleeding and, 58 Scottish Intercollegiate Guidelines Network (SIGN), 92 scrub typhus, 125, 140 section 5(2) order and holding a patient, 129 Segond fracture, 133, 149 seizure. See also epilepsy eclamptic, 49 generalised, 34 self-harm, suicide and, 20 septic arthritis, 87 diagnosis of, 71 septic shock, 123 serum osmolality, calculating, 82 serum sodium, analysis of, 95 serum T4 level, 129 serum TSH level, 129 sexual assault, by penetration, 19 sexual exposure, high-risk, 26 Sexual Offences Act, 5, 19 sexually transmitted infections, 125 Sgarbossa criteria, 14 shoulder abductors, 135 sickle cell anaemia, 41, 125 risk of acute chest syndrome and, 59 Sideroblastic anaemia, 125 Sit-Up, Squat Stand (SUSS) test, 36, 51 skin burns, 138 slapped cheek rash, 42 slipped upper femoral epiphysis (SUFE), 129 risk factors for, 144 slit lamp examination, 39, 88 small-cell lung cancer, 71 smoke inhalation, 37 snakebite, antivenom and, 69, 83–4 Society for Endocrinology, 137

sodium nitrite, for severe cyanide poisoning, 53 sodium thiosulphate, 53 sore throat, Ampicillin-based antibiotics for, 124, 138 sphenopalatine artery, 111 branch of the internal maxillary, 96 branchof the internal maxillary, 110 spinal cord injury, 2, 15 spontaneous bacterial peritonitis, 99 spotted fever group rickettsioses, 140 sprain, without imaging diagnosis help, 4 staphylococcal infection, 124 staphylococcal toxic shock syndrome, 72 desquamation, 88 diagnostic criteria for, 88 Staphylococci, 88 Staphylococcus aureus, 41, 85 Staphylococcus epidermidis, 68 steroid therapy, NICE criteria on, 137 steroid treatment, indication not to commence, 123 streptococcus, 88 group A, 9, 24, 30, 113, 128 streptococcus pneumoniae, 41, 85 streptococcus pyogenes, 82, 85 stress fractures, 126 smokers’ risk of, 127 stress fractures, diagnosing with magnetic resonance imaging, 141 stridor, 72, 89 stroke, risk of, 71, 87 subarachnoid haemorrhage, 2, 15 subcutaneous nodules, 112–13 subcutaneous vein thrombosis, fixed staining and, 135 sudden unexpected death in infancy (SUDI), 128, 143 SUDI paediatrician. See paediatricia, sudden unexpected death in infancy (SUDI)

https://doi.org/10.1017/9781009003834.012 Published online by Cambridge University Press

Index suicide attempted, 64 red flag risk factor for, 6 risk of, 20 superadded bacterial infection, 123 superior vena cava (SVC) filter, 23 obstruction, 71, 87 supine hypotension syndrome, 127 suspected pulmonary embolism (PE) investigative protocol for, 6 sutures, lidocaine local anaesthesia and, 5 swollen calf, 38 swollen leg, 55 synchronised DC cardioversion, 77 syncopal episode, 67 syndrome of inappropriate antidiuretic hormone (SIADH), 61 syndrome of inappropriate diuretic hormone (SIADH) diagnosis of, 74 synovitis diagnosis of transient, 71 transient, 87 systemic lupus erythematosus, 122 systolic blood pressure, 50–1 target lesions, 94 erythema multiforme, 109 tarsometatarsal joint complex, tender, 94–5 tarsometatarsal ligamentous joint complex, 109 teardrop sign, 126, 140 temperature, 20 core, 21 temporal arteritis, diagnosis doubts about, 34 tenosynovitis, 116 test sensitivity of a, 79 specificity of a, 79 testicular pain, 65 Tetralogy of Fallot (ToF) female with, 126

165

hypercyanotic episodes (TET Spells), 140 Thalassemia, 125 thermal burns, escharotomy in, 40 thigh pain, acute, 35 thorax, abdomen and pelvis (CT-TAP), computerised tomography (CT) scan of, 10 throat cancer, treatment for, 30 throat infection, 97 thrombocytopenia, 6, 21, 118 immune, 112 thrombosis, causes of, 87 thyroglossal cyst, 69, 83 thyroid storm diagnosis of, 129, 143–4 gastrointestinal-hepatic dysfunction, 143–4 tibiofibular syndesmosis, disruption of the, 149 ticagrelor, 131 tongue protrusion, 83 and neck lump, 68–9 tonsillitis bacterial vs viral, 138 child with suspected, 124 tooth avulsion of a permanent, 27 excessive bleeding after extraction of a, 97 re-implantation of the, 27 total body surface area (TBSA) of burns, 104 Toxbase, 22, 78, 83, 118, 138, 146 tracheal tube, internal diameter, 115–16 tracheostomy emergency, 30 long-term, 30 management of emergency, 44 Traffic Light System, NICE, 121, 134 tranexamic acid, 98 effect of on patient, 3 transfusion associated circulatory overload (TACO), 46

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166

Index

Transfusion Handbook (JPAC), 46 transfusion-related acute lung injury (TRALI), 46 transient ischaemic attack (TIA), single, 48 transient loss of consciousness (TLoC), 141 transient synovitis diagnosis of, 71 differentiating from septic arthritis, 87 trauma patient, computerised tomography (CT) scan of, 10 traumatic brain injury, effect of tranexamic acid after, 3 travellers, returning, 125, 132, 140 Travellers’ diarrhoea, 132, 147 Trethowans’sign, 144 Triage Sieve Score, mass casualty incidents, 50–1 Triage Sort score, 35 Truvada, 26 tuberculosis, 42 tumours incidental adrenal, 24 solid, 42 tumour lysis syndrome, 34, 49 UK immunisation schedule, 148–9 ulipristal acetate, 58 ultrasonography, 120 ultrasound, point-of-care, 81 umbilical cord prolapse, 4, 18 unfractionated heparin, 21, 132, 147 upper gastro-intestinal haemorrhage, 98 upper incisor, treatment to save an avulse, 12 upper respiratory tract infection, 87 upper-extremity deep vein thrombosis (UEDVT), 8, See also deep vein thrombosis (DVT)

upward gaze, paralysis of, 4 ureteric stones, diagnosis of, 52 urinary ketones, 139 urinary retention, 15–16 urinary tract infection patients under 16-years-old, 108 urinary tract infection (UTI), in a baby, 94 ursodeoxycholic acid, 130 variceal bleed, management of a, 58 vasovagal syncope, and driving, 48 venous thromboembolism (VTE), 66 ventilation-perfusion mismatch, 145 ventricular fibrillation (VF), 7, 21 ventricular tachycardia, immediate treatment of, 77 vertebrobasilar stroke, 44 vertical nystagmus, 44 vertigo cause of sudden onset persistent, 30 persistent with vnystagmus, 44 sudden onset persistent, 30 vestibular neuritis, 44 Viridans group streptococci, 70, 85 visual disturbance, 39 vomiting cause of in a 3–week-old child, 64 pregnant woman presents with intractable, 124 projectile non-bilious, 77–8 von Willebrand disease, 112 Wallace Rule of Nines tool, 91, 104 Warfarin, 57 water retention, risk of, 27–8 Wells pulmonary embolism (PE) score, 55, 63, 77 for deep vein thrombosis (DVT), 38 Westley croup score, 72, 89 Westley score. See also croup wheeze, bilateral, 36–7

https://doi.org/10.1017/9781009003834.012 Published online by Cambridge University Press

Index Wolff-Parkinson-White syndrome, 76 World Federation of Neurosurgical Societies (WFNS) grading scale, 2, 15 wounds, 100 high-risk tetanus prone, 32 local anaesthesia for, 70 management of, 32

management of stabbing, 32 neck, 32 tetanus prone, 46–7 wrist extensors, 135 wrist flexors, 135 Zika virus, 125, 140 β-Thalassemia, 125

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167

https://doi.org/10.1017/9781009003834.012 Published online by Cambridge University Press