New Year's Eve in Accident & Emergency!

Sadly, I saw my New Year in in Accident and Emergecy - as a doctor of course! The temptation of a well paid locum was too much!

It's quite enjoyable and satisfying to see some acute cases which can often be sorted quite easily. It was quite unusual that there was only one intoxicated patient and the rest were normal run-of-the mill A&E cases. The following are some of the cases I saw that I feel have some learning points.

Pulled Elbow

My first case was a 3 year-old child who wasn't using her right arm after she was caughtby her outstretched hand while sliding down a slide. She was holding her arm by her side, not bending it and not using it to play with. On examination there was no deformity, swelling or bruising and it seemed to be tender over her radial head. Putting firm pressure on the radial head with my thumb while pronating the forearm and flexing the elbow produced a satisfying little click (along with a bit of crying)!

After leaving her to play for 15 minutes it was quite obvious she was now using the arm much more normally.

A pulled elbow occurs when sharp traction is applied to a child's forearm/hand, for example when they trip whilst walking holding a parent's hand. The radial head slips slightly out of the annular ligament whcih usually holds it close to the proximal ulna. X-ray would appear normal so is not indicated unless there is suspicion that there may be a fracture (based on history). The above procedure will relocate the radial head and no more treatment is required except for warning the parents to try to avoid pulling on their arm!

Dog Bites

I saw 2 people with dog bites. The first was a child who presented over 12 hours after the attack which rang alarm bells in my head that a delayed presentation is inappropriate and may signify NAI or neglect. Social services were contacted.

The second patient was an adult with a partial amputation of his ear in addition to some severe neck lacerations. Fortunately there was no significant neurovascular damage. It is important to clean animal bites well with copious irrigation, leave them open to heal by secondary intention and prescribe broat spectrum antibiotics that cover anaerobes (eg, co-amoxiclav) . However, in this case I couldn't just leave his ear handing off! So he was warned about the risks of infection but cleaning, antibiotics and a primary closure was advised and carried out in this case.

COPD Exacerbation

I saw a lovely 89 year old lady with a fever, cough with purulent sputum and shortness of breath for the last 4 days. She has been commenced on amoxicillin by her GP 2 days ago but had deteriorated slightly. She denied any significant smoking history but was on salbutamol and tiopropium which suggests a diagnosis of COPD has been made. Her chest demonstrated a diffuse wheeze but no signs of consolidation and her CXR showed emphysematous change only. On this basis I diagnosed an infective exacerbation of COPD which should normally be treated with at least 10 days of steroids in addition to antibiotics. This was commenced and she was observed overnight and discharged home the following morning.

RIF Pain

The final case that springs to mind was a 14 year-old boy who complained of vague abdominal pains that were worst in the RIF. He was off his food but had normal bowels, no nausea or vomiting, no urinary symptoms and no fever. On examination he was not tachycardic or febrile. He did declare tenderness over McBurney's point but there was no guarding here and psoas sign and Rovsing's sign were negative. Urine dipstick was also negative.

Although RIF pain alerts us to appendicitis, the history suggests it probably isn't because of minimal systemic upset and no clear migration of the pain from the midline. The examination virtually rules this diagnosis out although some would argue that it could be a very early appendicitis but discharge with a warning to come back if things get worse would still be adequate.

The final part of the examination of this child was crucial because we should never forget that gonadal pain is usually vague in the lower abdomen because of their embryological origin. Examination of the testicles showed a high riding, transverse and tender right testicle. Exploration under anaesthetic revealed testicular torsion so ipsilateral and contralateral orchidopexy was performed.

Delay in the diagnosis and treatment can lead to infertility so it is incredibly important to consider in any male with RIF pain Common misdiagnoses include renal/ureteric colic and appendicitis.