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You are the F1 working in the A and E department. A 56yr old female presents with a painful right hand having fallen over the earlier in the week on a night out. She has a background of well-controlled asthma, taking regular inhaled corticosteroids and rarely having to use her salbutamol.

Please take a focussed history and perform a relevant examination.

You are Becky Metasone, a 56 year old lady who is currently quite anxious about work. You have a history of depression, but you don’t like to talk about it. You have only just restarted your job after having a long time off due to the depression. This night out was actually your celebratory ‘welcome back drinks’, and you’re really worried that you can’t have anymore time off and you could lose your job because of this. This will be the main focus of your history, and you want a lot of reassurance that you haven’t broken anything.

PC: Painful right hand

HPC: Fell over this weekend while on a night out in town. You had been drinking quite a lot, and don’t remember too much about how or why it happened, but you were told you tripped over a curb onto your outstretched right hand. You are pretty certain you didn’t hit your head or lose consciousness. You carried on with your night out at the time, and just shook it off. You felt a bit embarrassed, but actually had a really nice time out. It was just what you needed, apart from this stupid wrist of course. In the morning it was quite bruised and swollen, and you thought you had sprained your wrist. However, its only got worse since then you have decided to go to A&E. It is still very painful, although the bruising and swelling have gone down slightly. It is painful to press over the top of the wrist/base of the thumb. Moving the wrist is also painful, and trying to type was agony. It doesn’t spread anywhere else. Sharp pain. No tingling, pins and needles or numbness. Elbow and finger joints aren’t painful. Moving it makes it worse, and resting it makes it better. You have been using paracetamol and ibuprofen which has helped lessen the pain. 5/10 when at rest. 8/10 when moved or pressed.

ICE: Thought you had just sprained it at the time, but this bruising has started you worry you a bit. Now worried whether you’ve broken it. You hope this won’t affect your work, as you’ve only just re-started your job, the bosses made it really difficult to get time off with your depression, and your concerned that if you ask for more time because of a broken wrist you might lose your job. You want to get an x ray to make sure 100% that nothing is broken.

PMH: Asthmatic, well controlled with brown preventer inhaler. Only rarely has to use blue one, when it gets cold or exercise. Had appendix out at 16. Had a lot of problems with your mood over the years, but you’ve been a lot better recently. (If asked directly - Post menopausal).

DH: Brown and blue inhaler – take brown one every day, blue one only in a blue moon, haha. Has been taking Paracetamol and ibuprofen (tablets and gel) for the wrist, but it hasn’t helped that much. Sertraline Didn’t tolerate Citalopram, had a lot of side effects. No known allergies.

FH: FH of heart disease, grandfather and uncle died of heart attack at 55 and thyroid disease (mother and sister hyperthyroid).

SH: A non smoker, never has – found it really difficult due to your asthma. Made such a big change to your life when they banned smoking indoors. Drinks quite a lot (binges at weekend with wine and spirits, drinks about 1 bottle of wine a week as well during week, but it used to be a lot more when your depression was bad). Just restarted old job as a secretary at a legal firm, have to do a LOT of typing, which is why you’re so worried about this injury to your wrist.

The student should take a focussed history, sensitively dealing with this lady’s ideas concerns and expectations. They should perform a REMS examination of the hand. The students differentials should sound something like this: ‘My differentials for this lady’s wrist pain are a simple sprain or a fractured wrist. My top differential would be a wrist fracture, specifically a scaphoid fracture given the tenderness and bruising in the anatomical snuff box’ Topics for discussion could include: • Initial investigations and management for wrist fracture • Specific management and investigations of scaphoid fracture (if not mentioned previously) • Complications of scaphoid fracture, particularly of avascular necrosis • Risk factors for fractures in this lady • Different types of wrist fracture and their mechanism of injury • Conditions that this lady might be at risk of given her risk factors (OA, osteoporosis, carpal tunnel), consider management and investigations for these