Trainee Advanced Clinical Practitioner Diary- Day 5 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 5

Fractured first rib in RTC. Discussion about this type of fracture inferred that this could potentially be a very serious injury because of some of the structures around the site that maybe involved e.g azygous vein/ subclavian vessels etc.

Traumatic first rib fracture: is angiography necessary?

 Cage score.

Patient questionnaire is a screening test for problem drinking and potential alcohol problems.

  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang over (Eye opener)

 Penetrating eye injury:

Suspected Penetrating Eye Injuries

    1. Do not force eyelids open -pressure on the lids may cause extrusion of ocular contents.
    2. Do not attempt to remove a protruding foreign body from the globe.
    3. Fast the patient from the time they are seen.
    4. Use appropriate analgesia. Consider NSAIDs. If opiates are required consider concurrent antiemetic as vomiting increases intraocular pressure and may cause expulsion of ocular contents. Use ondansetron rather than agents which may precipitate dystonic reactions.
    5. Notify ophthalmology for all suspected penetrating eye injuries.
    6. After discussion with ophthalmology, image the orbit (X-ray or CT) in cases where an intra-ocular foreign body is suspected.

 Signs suggestive of globe perforation

    • Severe loss of vision.
    • Squashed or distorted appearance to globe
    • Ocular contents extruding from globe (iris and retina ö pigmented, vitreous – clear jelly).
    • Distorted or peaked pupil.
    • Loss of red reflex.
    • Relative afferent pupil defect.
    • Loss of ocular motility.
    • Shallow anterior chamber
    • Chemosis -bulging of the conjunctiva.

 Orbit “blowout” fractures

Orbit blowout

Trauma to the orbit may lead to increased pressure in the orbit such that the thin bone of the orbital floor bursts. This manifests as the ‘teardrop’ sign which is due to herniation of orbital contents into the maxillary antrum.



Patient presented with abdominal pain. Challenge was to think about possible differential diagnosis from the symptoms offered. Previous diverticulitis, diarrhoea and some bleeding. Generalise abdominal pain with some tenderness in the epigastric region.


  • Diverticulitis
  • Pancreatitis
  • UTI
  • Viral illness
  • AAA
  • DU
  • Renal colic.

Patient had fallen. Bang to head. It was established that patient had not lost consciousness, no dizziness post or prior to incident, no palpitations and no headache.

As patient was elderly it was important to also do an ECG and lying and standing BP. Also needed to check that had not incurred any further injuries as a result of the fall i.e. abdo/limb/joint problem.

Needed to establish that patient was not on warfarin as this make have affected decision to send for CT scan. Also need to check for retrograde or antegrade amnesia.

With neck exam on this patient cervical spine was palpated and paraspinal muscles at cervical level were checked. Range of movement was established. A check was made for mastoid bruising as this may indicate base of skull fracture.

Abdo pain in male from puberty to approx 20 should also be checked for torsion of the testicles.

Signs and symptoms of testicular torsion include:

  • Sudden or severe pain in the scrotum
  • Swelling of the scrotum
  • Abdominal pain
  • Nausea and vomiting
  • A testicle that’s positioned higher than normal or at an unusual angle

Painful knee examination. Checked for:

  • swelling
  • Bruising
  • Effusion
  • Crepitis
  • Bony tenderness

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