Volume 13, Issue 2, Pages 53 – 100 (2014)

Picture Quiz Answer: A Life-Threatening Cause of Abdominal Pain

Picture Quiz, Volume 13, Issue 2, Pages 53 - 100 (2014)

Case Outcome:

Following review of the abdominal x-ray, an urgent CT aortogram was undertaken which showed an abdominal aortic aneurysm (AAA) measuring 13 cm in width and 18.9 cm in length (Figure 2 and 3). Furthermore there was some stranding of tissue around the margins of the aorta superiorly consistent with an early leak of the aneurysm. Surgical repair of the giant AAA was carried out; however two days after operation the patient deteriorated suddenly and despite all attempts at resuscitation, he passed away.

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Problem based review: The patient presenting with hyponatraemia

Trainee Section, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

Hyponatraemia is the most common electrolyte anomaly and is associated with significant morbidity and mortality. Patients with severe hyponatraemia often present to acute medical units with non-specific symptoms which can progress to overt neurological manifestations. There are many causes of hyponatriaemia, the most common being drug-induced causes, particularly thiazide diuretics, and the Syndrome of Inappropriate ADH Secretion (SIADH). Initial assessment should include a careful evaluation of the patient’s volume status, which helps to identify the most likely cause. This article utilises a recent case which presented to our AMU to illustrate the importance of a careful and systematic assessment of patients presenting to hospital with hyponatraemia. The new vasopressin receptor antagonists are explored as an option for the management of severe hyponatraemia.

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British Society of Echocardiogaphy Adult Accreditation: An Unrealistic Expectation for Acute Physicians?

Trainee Section, Volume 13, Issue 2, Pages 53 - 100 (2014)

Acute medicine trainees can chose to pursue a specialist interest as part of their training. I decided to train in echocardiography and I’m currently close to attaining the BSE Adult Transthoracic Echocardiography Accreditation. I have found echocardiography a useful tool to rapidly answer important clinical questions and aid management of the acutely unwell patient. For example, an 85 year old was admitted with acute shortness of breath, hypoxia despite high flow oxygen and a normal CXR. A bedside echocardiogram revealed thrombi in the right atrium with mild right ventricular strain. A CTPA confirmed a saddle embolus and she was admitted to CCU as a precaution in case thrombolysis was required. In another case, a 75 year old was admitted to the emergency department after successful DC cardioversion for VF arrest 10 days post primary PCI for anterior STEMI. The post arrest ECG did not show new acute ischaemia. He had 2 further VT arrests with successful DC cardioverison to sinus rhythm. An echocardiogram revealed an acutely dilated right ventricle and he was thrombolysed for a high risk pulmonary embolus.

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Trainee Update May 2014

Trainee Section, Volume 13, Issue 2, Pages 53 - 100 (2014)

Acute Medicine Awareness Week (AMAW) 14-20 July

You may have seen in the Springspring newsletter that there was a plan to do a “virtual marathon” from Edinburgh to Brighton for this year’s AMAW using a GPS tracker App. However, this has now been changed back to same format as in previous years but you can arrange any event you like from parachute jumping to a cake stall. In order to register your AMAW event contact SAM via communications@ acutemedicine.org.uk.

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Can someone call my PA?

Viewpoint, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

The aim of this paper is to outline the background of the Physician Associate (known in the USA as physician assistant1) role in the USA and follow its recent journey to the UK where it is becoming a rapidly developing new healthcare role. Through the use of two case studies from UK Hospital Trusts who are currently utilising Physician Associates (PAs) in their workforce we describe the implementation and development opportunities for the role, with particular reference to their role in Acute Medicine teams of the future.

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Picture Quiz Question: A Life-Threatening Cause of Abdominal Pain

Picture Quiz, Volume 13, Issue 2, Pages 53 - 100 (2014)

Case Report:

A 76 year old man presented to the emergency department with gradual onset abdominal pain over a period of 24 hours and generalised lethargy. The abdominal pain was central with no radiation and was described as an ache by the patient. There was no history of vomiting. He had a 45 pack-year history of smoking. He was noted to have a blood pressure of 150/60 mmHg, pulse of 130 beats per minute, temperature of 36.5oC and saturations of 95% on room air.

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Reversible Cerebral Vasoconstriction Syndrome: an important cause of thunderclap headache

Case Reports, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

Reversible cerebral vasoconstriction syndrome (rCVS) is an important cause of acute severe headache that is poorly understood and under-recognised. It typically presents with recurrent thunderclap headaches and is characterised by multifocal, segmental constriction and dilatation of the cerebral arteries, shown by a ‘string of beads’ appearance, on cerebral angiography. We describe a case of rCVS in a 39-year-old male presenting with post-coital thunderclap headaches following a whiplash-type injury.

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ST-Segment Elevation in Patients With Cocaine Abuse and Chest Pain

Case Reports, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

Use of cocaine may complicate the diagnosis of myocardial infarction (MI) and may influence treatment strategy. Patients with symptoms suggestive of acute coronary syndrome (ACS) should be questioned about the use of cocaine. Initial management of cocaine users presenting with chest pain and ST segment elevation should include administration of glyceryl trinitrate (GTN). Assessment for resolution of chest discomfort and ECG changes should be undertaken before fibrinolytic therapy or angiography is considered. We present a case of patient with chest pain (CP) and ST elevation after cocaine use, whose symptoms and ST changes promptly resolved after medical therapy. Our case highlights the importance of medical therapy in patient with CP and ST elevation after cocaine abuse, before activating cardiac catheterization laboratory for emergent angiography.

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A giant cause of stroke

Case Reports, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

An 80 year old man presented subacutely with drowsiness and confusion. Subsequent MRI brain imaging demonstrated multiple posterior circulation infarcts. Extracranial vasculitis was suspected when his ESR was found to be high and vascular imaging showed multifocal irregular narrowing of both vertebral arteries. This was confirmed by targeted temporal artery biopsy, which showed chronic granulomatous inflammation typical of giant cell arteritis (GCA). The patient made a significant recovery following treatment with prednisolone.

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Pause for thought? Syncope and sinus arrest as the presenting feature of temporal lobe epilepsy

Case Reports, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

Some forms of focal epilepsy, including temporal lobe epilepsy, are rarely associated with ictal bradycardia and sinus node arrest. We report a case of a previously healthy man presenting with syncope in whom telemetry revealed sinus arrest. Initial treatment was with permanent pacemaker implantation and it was only following a subsequent grand mal seizure that other symptoms suggestive of temporal lobe epilepsy were documented. Anti-epileptic medication was subsequently commenced with resolution of all symptoms. There are few previously reported cases of syncope and documented sinus node arrest as the presenting feature of temporal lobe epilepsy.

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