Top 10 Diagnoses KCL

GKT school of Medical Educatio
2nd September 2020
Dr. Ben Balogun-Ojuri

Consultant in Emergency Medicine. Kings College Hospital
EMCC Induction
Top Emergency Department Presentations

Objectives
• To review the
• Clinical presentation
• Differentials
• Investigation and Management
• Of:
• The Most Common Presenting Complaints to the Emergency
Department
15th June 2020 Professor/Dr: Lorem Ipsum Topic title: Introduction Revision of Key Concepts and Models
Top 10 Reasons for ED Visits (*US data)
• 1: Abdominal pain
• 2: Chest pain, and related symptoms
• 3: Fever
• 4. Cough
• 5. Shortness of Breath
• 6. Pain, specified site not referable to a specific body system
• 7. Headache, pain in head
• 8: Back Symptoms
• 9. Vomiting
• 10. Throat Symptoms
• *
CDC-P; National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary
1: Abdominal Pain
• 30 – 40% have undetermined aetiology
• Immediately Life threatening Vs Self-Limiting
• Common Vs Unusual
• Surgical Vs Medical
History - 1
• Where
• Where is the pain?
• When
• When did it start & character (does it radiate anywhere?)
• Have you had the pain before?
• What
• What were you doing when the pain began?
• What does the pain feel like?
• What makes the pain better or worse?
• How
• How did it begin (sudden vs gradual onset)?
• How long have you had the pain?
• How painful on a scale of 0-10?
History - 2
• Associated Symptoms?
• PMH?
• Medical and Surgical
• GI: nausea, vomiting, anorexia,
• Drugs (prescribed and over the counter medications) constipation, diarrhoea, bleeding
• Social (e.g. alcohol, smoking and illicit drugs) • GU: dysuria, frequency, urgency, haematuria
• Gynae: pregnancy, menses, contraception,
fertility, sexual history, STIs, vaginal
discharge or bleeding, dyspareunia. Other
previous gynae history (pregnancy, surgery,
infections)
• Cardiopulmonary: cough, dyspnoea, chest
pain
Initial Assessment?
Examination
• General appearance
• Observations
• Pulse, BP, Sats, RR, Temp; EWS
• Abdominal examination
• Inspection, Auscultation, Percussion, Palpation (tenderness, guarding, masses, organomegaly)
• Pelvic
• Genital (including hernial orifices)
• Rectal
• Back
• Head-to-toe
Investigations
• Venous/Arterial gas
• Other bloods
• FBC, renal profile, LFTs, amylase, CRP
• BM
• Urine dipstick (+/- hcg)
• Bedside Ultrasound
• Other Radiology
• CXR (?erect), AXR, CT
• ECG
Case 1
• 64 year old man

• Acute onset central abdominal with radiation to right loin
• Constant with colicky exacerbations
• Nausea
• Sweating
• Loose stools with some fresh blood
• Darker urine
Case 1
• Pulse 120 irregular

• BP 108/79
• RR 32
• T 37.5C
• HS I + II + ejection systolic murmur
• Chest clear
• Abdomen soft
• Vaguely tender right loin
• No guarding/rebound
When Should an USS be Carried Out
• Whenever a AAA is suspected

• Includes:
• Unexplained back or abdominal pain in an older patient
• Renal colic in an older patient
• Syncopal episode in an older patient
• Suspicion on clinical exam
• When risk factors are present (IHD/PVD/age)
AAA – Presenting Symptoms
• Classic triad of rupture:

• Abdominal pain
• Abdominal mass
• Hypotension
• 75% are ASYMPTOMATIC
AAA – Imaging
Diagnosis Made: Now What?
http://www.vascularsociety.org.uk/wp-content/uploads/
2015/09/Best-Practice-guidelines-ruptured-AAA.pdf
Case 2
• 43 year old woman

• Acute onset right iliac pain which followed “slight belly ache” for 24 hours
• Sharp in nature
• Loose stools x 2 this am
• No urinary symptoms
• No PV discharge
• No PV bleeding
• LMP 1 week ago
Case 2
• Pulse 110 irregular

• BP 87/56 (patient says she normally has a low blood pressure)
• RR 24
• T 37.9C
• HS I + II
• Chest clear
• Abdomen tender with guarding and rebound RIF
• Tender McBurney’s point; Rovsing’s positive
Differentials
Pearls and Pitfalls
• Broad Differentials (Do not restrict diagnosis solely on the location of the pain)
• Consider appendicitis
• in all patients with abdominal pain and an appendix.
• It is a clinical diagnosis. Bloods tests (WCC) does not confirm/exclude diagnosis
• The presence and absence of fever cannot differentiate between medical and surgical causes
• Any woman of childbearing age (?<55yrs) is pregnant until proven otherwise
• Analgesia does not mask surgical causes of pain (i.e. prescribe it!)
• ECG and BM should be carried out in all patients with abdominal pain (especially the older population)
• A patient with unexplained abdominal or flank pain over the age of 50 should have a bedside US.
2: Chest Pain
Consider the 5 systems in the chest:
• Cardiac
• Heart and pericardium
• Pulmonary
• Lungs and pleura
• Gastrointestinal
• Oesophagus and upper abdominal contents
• Vascular
• Aorta and great vessels
• Musculoskeletal
• Chest wall
Case 3
• 72 year old man

• Central and left sided chest pain
• Onset 2 hours ago when walking up stairs
• Duration of approximately 30 minutes
• Associated with dyspnoea and nausea
• Now pain free
• History of hypertension (on amlodipine)
• No other medical problems
Case 3
• Pulse 78 regular
• BP 174/98
• RR 14
• T 36.2C
• Sats 98% room air
• HS I + II; no murmurs
• Chest clear
• Abdomen soft and non tender
ECG
KCH ACS Pathway
Case 4
• 72 year old man

• Severe, central and left sided chest pain
• Onset 2 hours ago when walking up stairs
• Duration of approximately 10 minutes
• Felt dizzy and collapsed
• Now pain free
• History of hypertension (on amlodipine)
• No other medical problems
Case 4

• BP 174/98
• RR 20
• T 36.2C
• HS I + II; ESM
• Chest clear
ECG
Typical Features of Pain
• Abruptness of onset
• Often maximal at time of onset
• Sharp or “tearing” in nature
• Anterior chest in 70-80% of type A dissection
• Upper back pain in 50% of type B dissection
• Less common features

• Sudden abdominal pain (but other causes more likely)
• Sudden radiation of pain to jaw/neck/throat
• Migratory pain (pain starts at site of onset of dissection and radiates to site of branch vessel). In 20% cases and more likely to be
unilateral
• Short duration (if dissection stops or re-entry tear)
Physical Examination
• In addition to General Assessment, LOOK FOR:

• Signs of haemopericardium
• Faint or absent heart sounds
• Pulsus paradoxus
• Distended neck veins
• Presence of shock
• Signs of branch vessel occlusion

• A difference of >20mmHg in blood pressure of each arm
• A weaker central or peripheral pulse compared to contralateral
• A palpable thrill or audible bruit over any of the pulses or abdominal aorta
• Signs of aortic root dilatation

• A wide pulse pressure
• A diastolic murmur over the aortic valve area
Presentations Without Pain
• 5-15% of presentations:
• Syncope
• Stroke
• Neurological deficit occurs almost simultaneously with dissection so no pain or patient dysphasic so may
not be able to express presence of pain
• Acute cardiac failure
• Paraplegia
Management – General Principles
• ABCs (obviously!)
• Analgesia
• Systolic BP should be actively reduced if >110mmHg
• Type A (involves ascending aorta/arch)
• Require urgent open surgery in order to prevent rupture into the pericardial sac
• If survives to surgery, in-patient mortality after surgery 26%
• Type B (descending aorta distal to subclavian)

• Usually managed medically
• May undergo endovascular stenting if persistent pain, rapidly expanding aortic diameter, or malperfusion of branch vessels
• Procedure successful in up to 95% of cases
Aortic Dissection
Differentials
Pearls and Pitfalls
• Broad differentials - consider diagnoses other than cardiac ischaemia
• Consider risk factors when making your diagnosis but do not exclude ACS/PE solely on the lack of risk factors
• TROPONIN & D-DIMER

• A –ve troponin does not mean that the pain was not cardiac
• A –ve d-dimer does not always mean that a PE is excluded
• CXR and ECG can be non-specific in establishing a diagnosis
• Duration of pain (short)/ no radiation to back does not exclude dissection
• Do not rely on the effectiveness of GTN or Gaviscon in contributing a pain to a cardiac or gastric origin
3: Fever
• Allergic Reactions
• Non-Infectious • Infectious
• CNS Injury
• Viruses
• Inflammatory Conditions
• Bacteria
• Medications/Overdose
• Fungi
• Neoplasm
• Parasites
• Hyperthyroidism
• Thrombo-embolic disease
History 1
• How long have you been unwell

• How high was the fever; is there a pattern?
• Medication history (including recent antibiotics and steroids)
• Infectious contacts?
• Travel?
• Past medical history; particular note to conditions which may make the patient prone to infections
• Indwelling medical devices (eg catheter)
History 2
Associated symptoms:
• Respiratory:
• SOB, cough, sputum, pleuritic pain
• GI
• N&V, abdo pain, diarrhoea, blood
• Skin/soft tissue
• Pain, rash, erythema, induration
• Musculoskeletal
• Pain on movement, swelling, non weight bearing
• GU
• Dysuria, discharge, dyspareunia, pelvic pain
• Head/CNS
• Dental, throat or ear pain, discharge, difficulty swallowing, headache, neck stiffness, photophobia, back pain, headache
Case 5
• 78 year old female

• “Off Legs”
• Unwell for approximately 2 days
• Lethargy
• Vomiting
• Drowsy
• Urinary incontinence
Case 5
• GCS 13 (E3, V4, M6)

• Pulse 104
• BP 90/48
• RR 20
• Sats 97%
• Temp 38.2 C
• Urine dip: nit +ve, 3+ leuc, 1+ protein, 1+ blood
Management
Antibiotics
• Every hour’s delay in giving antibiotics in Sepsis increases mortality by 7.6%

• Red flag sepsis = mortality of approx 20-50%
• Use your Trust’s local antibiotics guidance when prescribing
4: Headache
• Primary:
• Tension; Migraines; Cluster
• Secondary:
• Head trauma
• Vascular
• Stroke ,intracranial haemorrhage, subarachnoid haemorrhage, vascular malformation, arteritis, venous thrombosis, aterial hypertension
• Non-vascular intracranial
• High of low CSF pressure, inflammatory disease, intracranial neoplasm
• Infection
• Meningitis, encephalitis, abscess, other acute systemic febrile illness
• Metabolic
• Hypoxia, hypercapnoea, other metabolic abnormalities
• Substance use or withdrawal
• Neuralgias
• Ophthalmic
• Acute closed angle glaucoma
History
• How did the pain begin (sudden vs gradual)

• How long has it been present?
• What time of day is your headache worse?
• What were you doing when the pain began?
• What does the pain feel like?
• Where is your pain?
• Does anything make the pain better or worse?
• What medications are you taking/have you changed any medications?
• Associated symptoms (N&V, photophobia, neck stiffness, fever, visual changes)
• Past medical history
• Family history
Case 6

• Sudden onset severe right frontal headache
• Tired for a couple of days
• Slight blurred vision
• 3 vomits
• No neck pain
• No photophobia
• History of migraine
• Used paracetamol, ibuprofen with slight relief
Case 6
• GCS 15
• Pulse 78
• BP 124/68
• RR 14
• Sats 100%
• T 37.5 C
• No focal neurology
• No signs of meningism
• No rash
Red Flag Management Algorithm
Non Red Flag Management Algorithm
Pearls and Pitfalls
• Consider SAH in any patient who has presented with first or worst headache of their life
• Consider SAH and meningitis in patients presenting with a change in character, location or intensity of their
headache
• Always perform a thorough eye examination on patients with headache. Older patients may have acute closed angle
gaucoma; younger patients may exhibit papilloedema as a sign of intracranial hypertension.
• Consider carbon monoxide poisoning in a patient with flu like symptoms, headache and nausea, especially if other
family members are affected
• CT scanning is not 100% sensitive in diagnosing SAH
• Be mindful of diagnosing migraine to elderly patients with their first headache.
5 - Shortness of Breath
History
• How did the SOB begin (sudden vs gradual)

• How long has it been present? Have you had it before?
• Does anything make the SOB better or worse?
• Do you have chest pain?
• Do you have palpitations?
• Do you have any swelling in the lower extremities?
• Ask about upper respiratory symptoms
• Have you had a fever?
• Have you noticed any blood loss (sputum, vomit, stools, urine)
• Have you had any unintentional weight loss
• Past medical Hx
• Social Hx (occupation, travel, smoking, alcohol, drugs)
Examination
• ABC & General appearance

• Vital Signs
• Head, neck, ENT
• Pulmonary
• Assess specifically for signs of increased work of breathing as well as usual
inspection/palpation/percission/ausculation etc
• Cardiac
• Abdomen
• Eg distension/ascites/pregnancy
• Neurologic
• ?generalised muscle disorder/acute or chronic neuro condition
Differentials - 1
• Sudden • Intermittent
• Pneumothorax • Asthma
• VTE • Hyperventilation
• Aspiration
• Cardiac event –arrhythmia, MI • Progressive
• COPD
• Over Hours/Days • Fibrosis
• Pneumothorax • Pleural effusion
• VTE • Anaemia
• Aspiration • LVF
• Cardiac event –arrhythmia, MI • Pulmonary hypertension
The 6-Ps of Dyspneoa
Differentials – 2
• Remember the Non cardio-respiratory causes

• Metabolic/renal
• DKA, Renal failure
• Endocrine
• Thyroid disease, Cushing’s
• Haematological
• Anaemia, Methaemoglobinaemia
• Gastrointestinal
• Raised abdo. pressure (ascites, obesity, pregnancy)
• Toxins/poisons/drugs
• NSAIDs/β-blockers in asthma
• Psychologic
• Panic/anxiety
Case 7
• 32 year old woman

• Acute SOB
• Feels like a panic attack
• Transient episodes yesterday coinciding with her partner leaving her
• Had a faint yesterday
• History of anxiety, depression and moderate alcohol excess
Case 7

• BP 101/58
• RR 24
• T 37.2C
• HS I + II; no murmurs
• Chest clear
ECG
Wells Score
• clinically suspected DVT — 3.0 points

• alternative diagnosis is less likely than PE — 3.0 points
• tachycardia (heart rate > 100) — 1.5 points
• immobilization (≥ 3d)/surgery in previous 4weeks — 1.5 points
• history of DVT or PE — 1.5 points
• haemoptysis — 1.0 points
• malignancy (with treatment in 6/12) or palliative — 1.0 points
• Traditional interpretation
• Score >6.0 — High (probability 59% based on pooled data)
• Score 2.0 to 6.0 — Moderate (probability 29% based on pooled data)
• Score <2.0 — Low (probability 15% based on pooled data)
• Alternative interpretation (NICE)
• Score > 4 — PE likely. Consider diagnostic imaging.
• Score 4 or less — PE unlikely. Consider D-dimer to rule out PE.
Pulmonary Embolism - Management
• ABCs
• Supportive therapy
• Oxygen
• IV access +/- fluids
• Monitoring
• LMWH or heparin infusion
• Clexane; 1.5mg/kg
• Thrombolysis
• Alteplase; 10mg bolus then 90mg over 2 hours
• ECMO (extacorporeal membrane oxygenation)
Case 8

• Priority call
• DIB
• “asthma exacerbation”
• p110; BP154/88; sats 84%; RR 34; T37.9
• GCS 15
• 5mg salbutamol given en route
• ETA 3 mins
Case 8
• Pt unwell at home 3/7 increasing SOB. Greenish sputum Observation After

5 min
• PHx: COPD, last admission 1yr ago); 40 pack yr smoker; HR
Hypertension 124
• DHx: Long acting β-agonist/steroid inhalers, PRN nebs, noBPhome O2 160/95
Sat 98
• SHx: Lives with husband. Walks to shop 200m.
RR 36
GCS 15/15
pH 7.36
pCO2 6.9
pO2 14.3 (on 4l)
HCO3 28
COPD - investigations
• NICE GC101 (2010)

• 1.3.3.2 In all patients with an exacerbation referred to hospital:
• a chest radiograph should be obtained
• arterial blood gas tensions should be measured and the inspired oxygen concentration should be recorded
• an ECG should be recorded (to exclude comorbidities)
• a full blood count should be performed and urea and electrolyte concentrations should be measured
• a theophylline level should be measured in patients on theophylline therapy at admission
• if sputum is purulent, a sample should be sent for microscopy and culture
• blood cultures should be taken if the patient is pyrexial.
COPD – treatment 1
• Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of
COPD.
• If a patient is hypercapnic or acidotic the nebuliser should be driven by compressed air, not oxygen (to
avoid worsening hypercapnia). If oxygen therapy is needed it should be administered simultaneously by
nasal cannulae.
• The driving gas for nebulised therapy should always be specified in the prescription.
• Salbutamol 2.5 – 5 mg
• Ipratropium 500 mcg
• oral corticosteroids should be used, in conjunction with other therapies, in all patients admitted to hospital with an
exacerbation of COPD.
• Prednisolone 30 mg orally should be prescribed for 7 to 14 days.
• Patients with exacerbations without more purulent sputum do not need antibiotic therapy unless there is consolidation
on a chest radiograph or clinical signs of pneumonia.
• Initial empirical treatment should be an aminopenicillin, a macrolide, or a tetracycline. When initiating empirical
antibiotic treatment prescribers should always take account of any guidance issued by their local microbiologists.
• Intravenous theophylline should only be used as an adjunct to the management of exacerbations of COPD if there is
an inadequate response to nebulised bronchodilators.
Case 8 (cont)
Observation After 15 After 45
min min
Click icon to add picture
•Pt unwell at home 3/7 increasing SOB. Greenish
HR 124 118
sputum
BP 160/95 164/90
•PHx: COPD (no previous NIV, last admission
Sat 98 89 1yr ago); 40 pack yr smoker; Hypertension
RR 36 28
•DHx: Long acting β-agonist/steroid inhalers,
GCS 15/15 13/15
PRN nebs, no home O2
pH 7.32 7.28
•SHx: Lives with husband. Walks to shop 200m.
pCO2 7.2 8.7
pO2 14.3 (on 4l) 8.3
HCO3 28 29
“NIV should be considered in all patients with an acute exacerbation of

COPD in whom a respiratory acidosis (pH <7.35, PaCO2 >6 kPa) persists
despite immediate maximum standard medical treatment on controlled
oxygen therapy for no more than one hour”
Pearls and Pitfalls
• Normal Sats and pO2 does not exclude significant disease

• Absence of chest pain does not exclude ACS or PE in patients in dyspnoea
• Psychogenic dyspnoea is a diagnosis of exclusion. Do not forget to consider PE in patients presenting
with an “anxiety attack”. “Hysterical” patients may actually be hypoxic
• Do not assume that a patient with dyspnoea and a previous cardio-respiratory diagnosis is solely
presenting with an acute exacerbation of said condition.
Case 9
• 64 year old man

• Acute right lower back pain
• Onset apparently after twisting today
• Constant with exacerbations
• Sharp
• Nausea
• Sweating
• Slight relief with paracetamol and ibuprofen
Case 10
• 24 year old male

• IVDU and alcoholic
• Brought in by ambulance after being found by a passer-by lying in alley
• Incontinent of urine
• Cellulitis on legs – chronic
• Back pain – chronic
• Does not appear acutely unwell; “obs” normal
• He won’t leave the department….
Spinal Epidural Abscess (TB)
History
• How long have you had the pain?

• Where is the pain? Does is radiate?
• How would you describe the pain?
• How did the pain begin? Any history of trauma?
• What makes the pain better or worse?
• Have you had any weakness, numbness, or loss of control of your bowel or bladder?
• Associated symptoms: fevers, night sweats, weight loss, urinary, GI, respiratory symptoms
• Past medical Hx – specifically ask about cancer and drug use (illicit and prescribed such as steroids)
• Family and Social Hx
Examination
• General appearance
• “Observations”
• Chest
• Abdomen
• Back
• PR
• Neurologic.
6: Back Pain
• Mechanical:
• Lumbar muscular strain/sprain
• Degenerative disease
• Spondylolisthesis
• Intervertebral disc herniation
• Spinal Stenosis
• Fracture (traumatic; osteoporotic)
• Congenital (kyphosis; scoliosis)
6: Back Pain
• Non-Mechanical
• Spinal Disorders
• Neoplasia – metastiatic, primary, myeloma, leukaemia
• Infection – osteomyelitis, discitis, paraspinal/epidural abscess, shingles
• Inflammatory arthritis – ankylosing spondylitis, Reiter’s, Psoriatic spondylitis, inflammatory bowel disease
• Paget’s disease
• Scheurmann’s disease (osteochondritis)
• Visceral Disorders
• Pelvic – prostatitis, endometriosis, PID
• Renal – calculi, pyelonephritis, perinephric abscess
• Vascular disease – AAA, aortic dissection
• GI disease – pancreatitis, cholecystitis, perforated bowel
Assessment
Pearls and Pitfalls
• Failure to consider “Red Flags”

• Failure to recognise the small proportion of patients with serious disease
• AAA (or ever rarer, dissection)
• Cancer (primary or mets)
• Cauda equina or other cord compression syndromes
• Epidural abscess or spinal infection
• Vertebral fractures
• Assuming that these patients “just need analgesia” but also conversely, not adequately analgesing them
Any Questions?
Summary
• Strategies in assessing patients with the 6 most common presenting complaints to the ED:
• 1: Abdominal pain
• 2: Chest pain
• 3: Fever
• 4: Headache
• 5: Shortness of Breath
• 6: Back Symptoms
• Key differentials
• Red flags and pitfalls
Thank you
Contact details/for more information:
Dr. Ben Balogun-Ojuri

Ben.Balogun-ojuri@nhs.net
www.kcl.ac.uk/contacts
© 2020 King’s College London. All rights reserved

Top 10 Diagnoses KCL

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Top 10 Diagnoses KCL

Uploaded by

Copyright:

Available Formats

GKT school of Medical Educatio

2nd September 2020

Dr. Ben Balogun-Ojuri

Top Emergency Department Presentations

• 30 – 40% have undetermined aetiology

• Immediately Life threatening Vs Self-Limiting

• 64 year old man

• Pulse 120 irregular

• Whenever a AAA is suspected

• Classic triad of rupture:

• 75% are ASYMPTOMATIC

• 43 year old woman

• Pulse 110 irregular

Consider the 5 systems in the chest:

• 72 year old man

• 72 year old man

• Pulse 108 regular

• Less common features

• In addition to General Assessment, LOOK FOR:

• Signs of branch vessel occlusion

• Signs of aortic root dilatation

• Type B (descending aorta distal to subclavian)

• Broad differentials - consider diagnoses other than cardiac ischaemia

• TROPONIN & D-DIMER

• CXR and ECG can be non-specific in establishing a diagnosis

• Duration of pain (short)/ no radiation to back does not exclude dissection

• How long have you been unwell

• 78 year old female

• GCS 13 (E3, V4, M6)

• Every hour’s delay in giving antibiotics in Sepsis increases mortality by 7.6%

• How did the pain begin (sudden vs gradual)

• 26 year old female

• CT scanning is not 100% sensitive in diagnosing SAH

• Be mindful of diagnosing migraine to elderly patients with their first headache.

• How did the SOB begin (sudden vs gradual)

• ABC & General appearance

• Remember the Non cardio-respiratory causes

• 32 year old woman

• Pulse 140 regular

• clinically suspected DVT — 3.0 points

• 65 year old female

• Pt unwell at home 3/7 increasing SOB. Greenish sputum Observation After

• NICE GC101 (2010)

“NIV should be considered in all patients with an acute exacerbation of

• Normal Sats and pO2 does not exclude significant disease

• 64 year old man

• 24 year old male

• How long have you had the pain?

• Failure to consider “Red Flags”

Dr. Ben Balogun-Ojuri

© 2020 King’s College London. All rights reserved

You might also like