Station - Instructions for candidate
You are an intern in the Emergency Department of a regional Western Australian hospital.
Carmela Bianchi is a 74-year-old retired library assistant in the Emergency Department with severe pain in her left lower leg after grazing it on a garden step 36 hours ago. She is distressed despite repeated analgesia. Triage observations and a nursing handover are provided above.
| Triage observations | HR 124 regular, BP 96/ sixty mmHg, RR 26, SpO2 95% on room air, temperature 38.6 degrees C, pain score 9/10 |
|---|---|
| Nursing handover | The patient has required repeated doses of analgesia in the Emergency Department with limited relief. |
Results provided:
Blood tests
| Item | Value | Reference range |
|---|---|---|
| WCC | 22.4 x 10^9/L | 4.0-11.0 x 10^9/L |
| Neutrophils | 20.1 x 10^9/L | 2.0-7.5 x 10^9/L |
| CRP | 286 mg/L | <5 mg/L |
| Haemoglobin | 108 g/L | 115-155 g/L |
| Platelets | 318 x 10^9/L | 150-400 x 10^9/L |
| Sodium | 129 mmol/L | 135-145 mmol/L |
| Potassium | 4.8 mmol/L | 3.5-5.2 mmol/L |
| Urea | 12.4 mmol/L | 2.5-7.5 mmol/L |
| Creatinine | 142 umol/L | 45-90 umol/L |
| Glucose | 8.9 mmol/L | 3.5-7.8 mmol/L |
VBG
| Item | Value | Reference range |
|---|---|---|
| pH | 7.31 | 7.35-7.45 |
| pCO2 | 4.1 kPa | 4.7-6.0 kPa |
| pO2 | 10.8 kPa | 10.0-13.3 kPa |
| HCO3 | 15 mmol/L | 22-28 mmol/L |
| Base excess | -10 mmol/L | -2 to 2 mmol/L |
| Lactate | 4.2 mmol/L | 0.5-2.2 mmol/L |
| Na | 129 mmol/L | 135-145 mmol/L |
| K | 4.8 mmol/L | 3.5-5.2 mmol/L |
| Glucose | 8.9 mmol/L | 3.5-7.8 mmol/L |
Left tibia and fibula X-ray
| Item | Value | Reference range |
|---|---|---|
| Report | No fracture or radiopaque foreign body; no definite soft-tissue gas visible | - |
Left tibia and fibula X-ray: no fracture or radiopaque foreign body. No definite soft-tissue gas is visible.
imaging other - read aloud by the examiner
The bones are intact and aligned. There is soft-tissue swelling. No definite gas is visible in the soft tissues.
Look up an example image: Radiopaedia necrotising fasciitis plain radiograph
Your tasks are to:
- Take a focused history, including relevant background, medications and allergies.
- Perform a focused examination of the left lower-leg wound and peripheral vascular system, including vital signs. Describe what you would look for or do; the examiner will provide the findings.
- Request appropriate investigations. Results will be provided by the examiner when appropriately indicated.
- State the most likely diagnosis and two to four differentials, with brief justification.
- Outline the initial management plan, including analgesia, antimicrobial treatment, escalation, referral and safety-netting.
- You do NOT need to summarise your findings to the examiner.
- Please verbalise the examination steps and the investigations you would request.
- You do not need to write prescriptions or perform a procedure; state the drug, dose, route and immediate escalation plan verbally.
This is a 10-minute station, with 2 minutes of reading time.