Possible ectopic, ST changes in black male, questions for gynae history, fractured ribs and facial bone exam.

Lady presented with 4 hour onset of lower abdominal pain. 2 weeks previously had positive pregnancy check.
On examination abdo was soft but tender in the lower quadrants. Had some PV bleeding.
Pregnancy test now negative.
Discharged home with safety net advice i.e. return if greater bleeding, clots or pain progresses and does not settle with analgesic.

Up to 10% of women with ectopic pregnancy have no symptoms, and one-third have no medical signs.[11] The symptoms are often non-specific and difficult to differentiate from those of other genitourinary and gastrointestinal disorders, including appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or urinary tract infection.[11] Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 4 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.
Early signs include:
Vaginal bleeding; The amount varies, although classically there is a complaint of “spotting”. Heavy bleeding, in the absence of ultrasound or hCG assessment, may lead to a misdiagnosis of miscarriage.[11]
Abdominal pain, which is often a late or even absent symptom.[11]
Less common features of ectopic pregnancy include nausea, vomiting and diarrhea.[11]
In ruptured ectopic pregnancy, there may be abdominal distension and abdominal tenderness, peritonism and hemorrhagic shock.[11]
A patient may be excessively mobile with upright posturing, in order to avoid intrapelvic blood to swell further up the abdominal cavity and cause additional pain.[12]


Learning point:
Signs for possible ectopic can include shoulder tip pain, postural blood pressure fall, collapse. Investigate for evidence of previous ectopics.
Tachycardia always needs referral.
If we had been concerned with this lady then would have ordered a Beta HCG, progesterone, FBC/UE’s and a group and save.


Male presented with ? Chest pain.

Central chest pain – associated with food. Ate last night, struggled to swallow. No history of cardiac problems, no family history.

Has had this in the past with barium swallow in the past which was NAD.

On examination cardiac NAD. Abdo some tenderness to left flank.

ECG ?ST elevation:

ECG Black male ST elevation

Global ST elevation is normal variant in black male.

ST Segment Elevation in conditions other than acute MI

Patient presented with possible gynae problem. Learning point was question types used in this circumstance:

Urine sample?




Discharge- smelly/colour?

Pain- during sex?


Weight loss

Gentleman with left flank pain. Fell from back of lorry and hit towbar. Presented in A/E two days ago and was discharged with painkillers and advice. On my initial exam I was concerned about possible liver problem as after my exam most of the pain seemed to be over the liver.

When ACP examined they were more thorough as establishing the exact location of the pain which seemed to confirm that it was more likely related to the injury to the ribs.

Learning point: need to be more thorough at establishing where the pain is.

Patient presented with painful nose. Had been assaulted the night before and punched in the face 5-6 times. Lost conciousness for 10-15 minutes.

I took history but needed to be more thorough in establishing timeline.

ACP checked cranial nerves and pupillary response. Also palpated zygoma, maxilla and mandible for any evidence of fracture.

Examined nose for deviated septum, heamatoma or discomfort and bleeding.

Advice given to return if any vomiting, headache, blurred vision.

Examination of the face

facial bones

Originally posted 2014-10-27 22:03:19. Republished by Blog Post Promoter

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