Volume 18

Struggling with the last breath: breathlessness at the end of life on the AMU

Clinical Reviews, Volume 18, Issue 2, Pages 61 – 136 (2019)

Breathlessness is one of the most common symptoms experienced at the end of life, affecting all areas of a patient’s life. It is frightening and leads to high rates of emergency hospital attendances. Often, there is no easily reversible cause and patients are admitted to the acute medical unit (AMU) in order to manage their symptoms with little overall benefit – frustrating patients and clinicians alike. This review reminds the generalist of the significance of breathlessness as a symptom. It highlights the management strategies available to effect improvement and gives practical tips on how this can be achieved within the busy and time-pressured environment of the AMU.

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Death after Discharge – Every heart beat counts (probably)!

Guest Editorial, Volume 18, Issue 2, Pages 61 – 136 (2019)

The assumption would be that patients who are discharged from an emergency or acute medicine department have been thoroughly assessed and are good to return to the safety of their own home. An unplanned death after discharge from hospital is the worst-case scenario for patients, families and indeed clinicians. In order to prevent adverse events after patients leave hospital most units have a multi-layered system to capture risk that includes triage, recording of vital signs, basic blood tests, understanding of existing past medical history and assessment by a senior clinician to add experience and intuition. Discharge decisions depend on a balanced review of all these parameters and a discussion with patients about residual risks. Only after this will patients go home. Despite this a small percentage of patients pass away unexpectedly within days after leaving hospital.

Death after Discharge – Every heart beat counts (probably)! Read More

Acute management of cellulitis: A review

Clinical Reviews, Volume 18, Issue 2, Pages 61 – 136 (2019)

Cellulitis is an acute localised skin infection, usually accompanied by symptoms such as fever and rigors, nausea, and vomiting. It most commonly affects the lower limbs, although it can involve any part of the skin. It presents as area of redness and inflammation of the skin, with associated pain and swelling.

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Malignant renal obstruction without dilatation

Case Reports, Volume 18, Issue 2, Pages 61 – 136 (2019)

A 61 year old male presented with a one-week history of abdominal pain and loose stools. He had recently received treatment for cellulitis with flucloxacillin. He was anuric on presentation requiring haemodialysis. His ultrasound scan showed patent vessels with no signs of obstruction.

A kidney biopsy revealed tubulointerstitial nephritis, attributed to recent treatment with flucloxacillin. A week later he developed lower limb thromboembolic disease triggering further investigations. A FDG PET-CT scan revealed a large FDG-avid retroperitoneal mass causing non-dilated obstruction of both kidneys. Bilateral retrograde stents were inserted which resulted in a 1.6L diuresis and cessation of haemodialysis.

Non-dilated obstruction should be considered in anuric AKI, particularly in the context of malignancy, and may require a therapeutic trial of decompression.

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Dealer’s Dytonia (Croupier’s Cramp) – An Unusual Hazard Of Gambling

Case Reports, Volume 18, Issue 2, Pages 61 – 136 (2019)

Dystonia takes many forms and often presents acutely to emergency care. The diagnosis is often delayed because it mimics other more common conditions. This report describes a patient with a rare occupational dystonia, the typical clinical features of dystonia in general, and differentials to consider.

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Shortness of breath: a common symptom with a rare cause

Case Reports, Volume 18, Issue 2, Pages 61 – 136 (2019)

A 51-year old Caucasian male was admitted to the hospital with a history of breathlessness of one month duration. Prior to this he had been well. He complained that the shortness of breath had worsened over the previous 10 days and was associated with fatigue and fever. The antibiotics from his GP did not relieve his symptoms. He denied any cough, sputum or haemoptysis.

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A Chest X-Ray causing confusion

Picture Quiz, Volume 18, Issue 2, Pages 61 – 136 (2019)

A 91-year old female presented to Acute Medical Unit with a 2 week history of shortness of breath and haemoptysis. Her past medical history included osteoporosis, depression, irritable bowel syndrome, asthma, cataracts, and a colonic polypectomy. Her medications: Citalopram 10 mg, Co-codamol, Beclomethasone 200 mcg inhaler, Salbutamol MDI inhaler, Omeprazole 20 mg and Alendronic acid. She was an ex-smoker with a 20-pack year history who had stopped smoking 40-years ago. She did not drink alcohol and lived alone independently.

A Chest X-Ray causing confusion Read More

The Source of the Problem

Picture Quiz - Answers, Volume 18, Issue 1, Pages 1 – 60 (2019)

The portable chest x-ray (Figure 1) shows a widened cardiac silhouette. An endotracheal tube is in situ, indicating the patient is now intubated.

The ECG (Figure 2) shows sinus rhythm with widespread mixed convex and concave ST elevation, most notable in V4, V5 and the lateral leads. There is a suggestion of PR depression in the inferior leads.

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Non traumatic spinal epidural haematoma

Case Reports, Volume 18, Issue 1, Pages 1 – 60 (2019)

Spinal epidural haematoma is a rare condition, which may be due to trauma, surgery, epidural catheterisation or disorders of coagulation. We report a case of 60 year old lady who was on warfarin for Atrial fibrillation (AF) presented with history of non-traumatic sudden onset pain in both legs and difficulty in walking. Magnetic resonance imaging (MRI) spine demonstrated epidural haematoma which was treated conservatively. Another dilemma was anticoagulation for AF. We examine the options to manage such case.

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