Trainee Advanced Clinical Practitioner Diary- Day 6 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 6

Ludwigs Angina, Shoulder Impingement, allergic reaction, Difficulty in breathing. PERC score.

PERC Score:

“PERC is a useful clinical decision rule to help rule-out pulmonary embolism in patients a clinician’s gestalt suggests are low risk. It was developed by Kline in 2004 and validated by him in a prospective, multicenter trial in 2008. As outlined by very well by Chris Nickson on Life in the Fast Lane in much greater depth, a very low risk patient (estimated at <15%) that is PERC(-) is as likely to be harmed by the work-up (think cancer, contrast nephropathy, anaphylaxis) as they are to have a PE in the first place (they are below the test threshold). Knowing this rule is helpful both clinically and for exam purposes (although I’d highly recommend using a smartphone checklist when applying the rule in clinical practice). I remember it using the (aptly named) HAD CLOTS mnemonic that I have added to the Boring Cards deck.

  • H – Hormone (estrogen) use
  • A – Age > 50
  • D – DVT or PE history (have they HAD CLOTS?)
  • C – Coughing blood
  • L – Leg swelling disparity
  • O – O2 sats < 95%
  • T – Tachycardia (>100bpm)
  • S – Surgery or Trauma (recent)”

Quote from BoringEM

Ludwigs angina.

Patient presented after having had dental abcess which had been treated. Then developed swelling around the sub mandibular area.

This diagnosis should be restricted to the following classical description:

●The infection begins in the floor of the mouth. It is characteristically an aggressive, rapidly spreading “woody” or brawny cellulitis involving the submandibular space.

●The infection is a rapidly spreading cellulitis without lymphatic involvement and generally without abscess formation.

●Both the submylohyoid and sublingual spaces are involved.

●The infection is bilateral.

Treatment with steroids and antbiotics was started.


Shoulder impingement

In between the rotator cuff tendons and the bony arch is the subacromial bursa (a lubricating sack), which helps to protect the tendons from touching the bone and provide a smooth surface for the tendons to glide over.

While a traumatic injury can occur eg fall, it is repeated movement of the arm into the impingement zone overhead that most frequently causes the rotator cuff to contact the outer end of the shoulder blade (acromion). When this repeatedly occurs, the swollen rotator cuff is trapped and pinched under the acromion.


Allergic reaction. No airway compromise but had potential.




No wheeze evident

If needed IM adrenaline 1:1000 0.5mg

Difficulty in breathing



Need to exclude recent travel/fever/chest pain/family illness

Remember to check lymph glands!

BTS Guidelines Asthma

Instructions for the correct use of a pressurised metered-dose inhaler (pMDI):

  • Remove the cap from the mouthpiece and shake hard.
  • If you have not used it for >1 week or it is the first time it has been used, spray into the air to check it works.
  • Stand/sit up straight and lift the chin to open the airway.
  • Take a few deep breaths and then breathe out gently. Put the mouthpiece in your mouth with teeth around it (not biting) and seal with your lips.
  • Start to breath in and out through the mouthpiece. As you start to breathe in, simultaneously press on the inhaler canister to release one puff of medicine. Continue to breathe in deeply to make sure it gets to the lungs.
  • Hold your breath for 10 seconds or as long as you can comfortably manage before breathing out slowly.
  • If you need another puff, wait for 30 seconds and shake the inhaler and repeat the process.
  • Replace the cap on the mouthpiece.

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