case study ( 2 )

:Present history
Faten shokry ahmed , 45 years old , female patient ,
born and lives in Ismailia , divorced with one offspring
( 29 years old ) . she was an employer 10 years ago but
now she 's a house wife . no smoking , no alcohol or
. drug abuse
:Complaint
The patient came to ER after falling from stairs
. complaining of pain in her left foot since 4 hours
: History of present illness
The patient was well till the condition started 4 hours
ago by falling from stairs and trauma to her left leg with
. pain and swelling in her left ankle joint
Pain was acute in onset and progressive course. It was
dull aching in character . not radiating to another site.
No associated symptoms ( nausea or vomiting ) . it
increased by standing and movement and slightly
.decreased by rest in bed
The swelling started as small nodule on her left ankle
joint with gradual onset and progressive course . it
increased in size all over the time and eventually
became orange like in shape after about an hour of the
accident and usage of bandage and ointment. It
increased in size by standing and movement and
decreased by rest in bed. There is slight limitation in the
movement. It didn't cause effects on general condition .
no wounds , no hemorrhage , no contusion , no
deformity . no other swellings in the body, no loss of
. consciousness , no convulsions
No drug intake , no drug allergy , no similar condition
.before . the last meal was from about 2 hours
.She had done x-ray and showed no fractures
: Past history
No similar conditions. No chronic diseases ( HTN ,
diabetes , IHD, hepatitis ) , no previous hospitalization or
operations , no previous blood transfusion , no drug
.intake or drug allergy
:Family history
.Irrevelant family history
:Menstrual history
Irregular menstrual cycle occurring every 1-2 months
and continued for about 2-3 days only with less amount
.than before
Before that, it was regular cycle and continued for 7-10
days. No previous complications from menstrual cycles.
Positive history of oral contraceptive pills intake about
.20 years ago
:General examination
General look : Patient is alert , conscious , oriented to
time , place and persons , average built , quiet facial
expression , normal decubitus , average intelligence ,
. she's cooperative
:Airway
.secure and patent
: Breathing
no respiratory distress , no chest deformity. respiratory
rate is 17 breath/min. symmetrical chest movement .
percussion on chest is resonant . normal breath sounds
. on auscultation
: circulation
.Capillary refill time is less than 2 sec. carotid pulse is felt
Pulse: Rate can't be assessed as it has irregular rhythm.
Mild weak volume . vessel wall wasn't felt. Equal on
both sides. BP is 170/110 mmHg. Temperature is 36.9•c
: Disability
GCS is 15 . pupils is normal in size , reactive to light and
equal on both sides. No loss of sensation or motor
.function
: Exposure
.No head , neck or spine findings
:Local examination
: Inspection
Single oval swelling on the left ankle joint slightly
deviated to lateral side , about 8×6 cm in size. Normal
. overlying skin. No special signs
:Palpation
Slightly cold, slightly tender , smooth surface , well
.defined edge and cystic in consistency
:Percussion
Dullness
: Provisional diagnosis
years old , female patient , presented to ER after 44
falling from stairs with pain and swelling on the left
ankle joint and no fractures , most probably due to leg
.contusion
 Scientific background
The ABCDE approach to all critically ill patients and it
composed of : A ( airway ) , B ( breathing ) , C
. (circulation) , D ( disability ) , E ( exposure )
: The underlying principles are
complete initial assessment and reassess )1
. regularly
treat life-threatening problems before moving )2
.to next part
assess effects of treatment and interventions )3
. that keep the patient alive
.call for help early)4
use all members of the team for assessment , )5
.attaching monitors and IV access

Airway & cervical spine control and protection

The most common causes of airway obstruction
are CNS depression , blood , vomitus , foreign
. body , infection , edema
We recognize patency of airway by talking to the
patient , shaking him , assessing difficulty in
.breathing , choking or noisy breathing
There are methods to assess airway obstruction
by head-tilt , chin-lift technique and jaw-thrust.
Also we can use LMA . we give the patient
oxygen to maintain normal saturation of his
. blood with oxyHb

Breathing
Most common causes of breathing problems are
CNS depression , muscle weakness, nerve
damage , pneumothorax , hemothorax ,
… , pulmonary embolus , infection
We look for any signs of respiratory distress ,
conscious level . we listen if there is noisy
breathing or abnormal breath sounds. We do
palpation , percussion and assess tracheal
. position
We must treat the underlying cause while we
. maintain ventilation and give oxygen

Circulation
Causes of circulatory problems are hypovolemia
(especially in multiple trauma patient ), acute
coronary syndrome, arrhythmia , hypertensive
.… , heart diseases , asphyxia , anemia
We assess by looking to patient if there is pallor
or cyanosis . feel patient's hand to assess the
temparture. We measure pulse , BP , urine
. output . record ECG monitoring
We give the patient IV fluids through 2 large pore
cannulae according to his state. And give him
. morphine , oxygen , nitrate and aspirin
Disability
We assess conscious level of patient by CCS score
or AVPU score. We assess state of pupils ,
lateralizing signs ( motor , sensory , reflexes ) and
.blood glucose level

Exposure
Remove clothes to enable full examination of
.chest , abdomen , back , genitalia and anus