Volume 11, Issue 3, Pages 129 – 185 (2012)

24 hour availability of echocardiography in Acute Medicine: time to get out of our ‘silos’!

Correspondence, Volume 11, Issue 3, Pages 129 - 185 (2012)

Dear Sir,

I read with interest the article by Ravikirti et al in the recent edition of Acute Medicine. The authors rightly highlight the potential for atypical presentations of tamponade following cardiac surgery, which has been reported previously. The investigation of any acutely unwell patient presenting after cardiac surgery should include some form of cardiac imaging. In the cases described the diagnosis was delayed, in part, due to the lack of an echocardiography service out-of-hours.

24 hour availability of echocardiography in Acute Medicine: time to get out of our ‘silos’! Read More

Problem based review: Pleuritic Chest Pain

Trainee Section, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

Pleuritic pain, a sharp discomfort near the chest wall exacerbated by inspiration is associated with a number of pathologies. Pulmonary embolus and infection are two common causes but diagnosis can often be challenging, both for experienced physicians and trainees. The underlying anatomy and pathophysiology of such pain and the most common aetiologies are presented. Clinical symptoms and signs that may arise alongside pleuritic pain are then discussed, followed by an introduction to the diagnostic tools such as the Wells’ score and current guidelines that can help to select the most appropriate investigation(s).

Management of pulmonary embolism and other common causes of pleuritic pain are also discussed and highlighted by a clinical vignette.

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Trainee Update

Trainee Section, Volume 11, Issue 3, Pages 129 - 185 (2012)

We hope that you have enjoyed the summer and the rare moments of sunshine! Now that you are settling into your new jobs since the recent changeover, we hoped you were able to make use of the extended trainee early bird discount for the October SAM conference in Manchester. If you have not yet booked spaces are still available and it’s a great way to meet new people and keep updated!

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Problem based review: The patient with ‘palpitations’

Trainee Section, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

Palpitations, or the sensation of a rapid or heavy heartbeat, are a common symptom in both primary and secondary care settings. Here we use a common presentation of palpitations to explore the best ways to assess and treat patients who present in this way. We hope that by using a structured approach to our assessment we will reduce the use of the ‘scattergun’ approach to diagnosis, thus preventing unnecessary investigation and hospital stay.

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An Unusual Cause of Abdominal Pain and Anaemia

Picture Quiz, Volume 11, Issue 3, Pages 129 - 185 (2012)

Case history

A 52-year old gentleman was referred to acute medicine by an out-of-hours general practitioner, with an unexplained ‘collapse’. The patient stated to have just ‘tripped and fallen’ with no new preceding symptoms immediately beforehand. Closer questioning revealed that he also been suffering from general malaise, shortness of breath, and five days of right upper quadrant pain and abdominal swelling. In the last six months he had lost thirtyeight kilograms in weight. He was diagnosed with a deep vein thrombosis in 1999 for which he had been treated with Warfarin. Both his parents had deep vein thromboses in their late 60s. He was a non-smoker, drank minimal alcohol and worked as a janitor. He was no longer anti-coagulated.

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Clinically Lean – “Cutting the Crap”

Viewpoint, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

Proponents of Lean Philosophy believe that successful businesses must reduce waste in working time and resources to a minimum, and maximise their use in productive work. The productive work of the Acute Medical Unit is to provide effective clinical management to a daily cohort of acutely ill patients. Many Clinicians are cynical about Lean. In this article, Dr Caldwell discusses how many clinicians complain of too much crap in the workplace, which gets in the way of swift, safe high quality clinical care. He argues that “Cutting the Crap” in the Acute Medical Unit is entirely consistent with Lean approaches to management of complex systems.

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Out with the old, in with the new? Case reports of the clinical features and acute management of two novel designer drugs

Case Reports, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

Methoxydine (4-MeO-PCP) and Methoxetamine (3-MeO-2-Oxo-PCE) are both commercially produced designer drugs with structural and biochemical similarities to phencyclidine (PCP). Although phencyclidine toxicity is well documented, its recreational use in present times is rare. With the advent of new designer drugs being available widely through internet sites, Acute Physicians should be aware of the clinical features and management of these potential toxins. We present a case of methoxydine ingestion (which to our knowledge has not been previously documented in any medical journals) and a case of methoxetamine ingestion, and discuss their history, contrasting clinical features and acute management.

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Enough to Bring a Lump to the Throat: Two Emergency Presentations to the Acute Medical Take

Case Reports, Volume 11, Issue 3, Pages 129 - 185 (2012)

Case number 1

An eighty nine year old woman was admitted with a two day history of abdominal pain and vomiting. Two months previously she had undergone a Hartmann’s procedure following a sigmoid perforation secondary to diverticular disease. A hiatus hernia had been noted on a CT undertaken prior to her recent surgery (Figure 1).

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An unusual cause of confusion and hyponatraemia in an elderly patient

Case Reports, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

A large proportion of patients presenting on the acute medical take are frail and elderly and a significant proportion of these will have symptoms such as confusion, reduced mobility and electrolyte disturbances. These symptoms are typically attributed either to the iatrogenic effects of prescribed medications, disturbances in fluid balance and possible infective causes. We describe the case of a gentleman who presented with delirium, reduced mobility and hyponatraemia who was subsequently found to have pituitary failure secondary to pituitary apoplexy.

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