Volume 6, Issue 3, Pages 93 – 136 (2007)

Picture Quiz: A case of mediastinal shift

Picture Quiz, Volume 6, Issue 3, Pages 93 - 136 (2007)

An 86 year old woman with a background of hypertension and arthritis presented to our medical assessment unit with 3 weeks history of mild dyspnoea and central chest discomfort. She did not have any past history of respiratory problems. She denied any cough, hemoptysis or weight loss. There was no significant family history. She was a life long non smoker and used to drink alcohol occasionally. She was taking enalapril 5 mg and amlodipine 5 mg daily. She was living alone and was independent and self caring.

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A Response to the Viewpoint Paper in Vol 6 issue 2

Viewpoint, Volume 6, Issue 3, Pages 93 - 136 (2007)

We read with interest the “viewpoint” by Sarbjit Clare and colleagues recommending that specialist registrars in acute medicine should receive patients in the resuscitation room.1 We agree that this is a valuable training experience, but question some of the assumptions made.

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Recurrent ‘Lactic’ Acidosis-a Cautionary Tale

Case Reports, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

Lactic acidosis can be caused by a variety of pathological conditions. We present a case of recurrent ‘lactic’ acidosis, which was eventually diagnosed to be secondary to ethylene glycol poisoning. Though there are a handful of cases reported in the literature, it is not widely known that glycolic acid (a metabolite of ethylene glycol) is measured spuriously as lactic acid by some point of care analysers. Literature review would indicate that this is a rare but potentially confounding factor in diagnosis. Given the nature of the pathology, we would suggest that greater awareness of the problem is important.

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A case of orthodeoxia platypnoea in a patient with adult polycystic kidney and liver disease with a patent foramen ovale

Case Reports, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

We describe a case of a patient with polycystic kidney and liver disease presenting with a 4 year history of shortness of breath. This was caused by a liver cyst pressing on the inferior vena cava, right atrium and ventricle, leading to a right to left shunt across a patent foramen ovale. This is consistent with the condition Orthodeoxia Platypnoea, which occurs when desaturation and dyspnoea occur in the upright position in association with an intra atrial shunt.

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Fatal intra-hepatic haemorrhage presenting with cardiac-type chest pain and anaemia

Case Reports, Volume 6, Issue 3, Pages 93 - 136 (2007)

A 79-year-old woman presented to the accident and emergency department with a short history of central chest pain radiating to the arm and epigastrum, associated with vomiting. There was no history of haematemesis and no recent change of bowel habit or melaena. She had a myocardial infarction 4 months previously and had a metal prosthetic mitral valve replacement for which she was anticoagulated with warfarin, maintaining an INR between 2.5– 3.5. On examination she appeared pale, but there were no other abnormal findings; the liver was not enlarged or tender.

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The admission of older patients to a dedicated short stay medical unit: learning from experience

Original Articles, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

The admission of older patients with acute medical problems to short stay medical units (SSMUs) is controversial in light of their longer expected length of in-patient stay (LoS), coupled with the greater resources required by such a department.

We undertook a prospective study of 120 consecutive SSMU patients aged 60 years or over, to find out whether information gained during the admissions process could predict which candidates would subsequently have a successful SSMU outcome, as well as to assess the overall suitability of the SSMU to older patients.

Our redesigned acute medicine services at Addenbrooker’s Hospital (Cambridge, UK) have taken account of our results, and we continue to admit older patients to our new Medical Short Stay Emergency Unit.

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Managing Pleural Disease in Acute Medicine (I): Pleural Effusion

Original Articles, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

A pleural effusion is the accumulation of fluid in the pleural space. It is a relatively common finding in clinical practice. The diagnostic approach to the patient presenting with a pleural effusion is aimed at defining the effusion as a transudate or an exudate. This review summarises the initial assessment and investigation of pleural effusions diagnosed during the acute medical take, and who should be referred for specialist advice. In addition, recent developments, including the measurement of NT-proBNP levels and diagnostic markers for mesothelioma, are presented.

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Asymptomatic Hyponatraemia on the Acute Medical Unit

Clinical Reviews, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

Hyponatraemia is defined as a serum sodium concentration of 135 mmol/L or less. It is the most common electrolyte abnormality, and can be associated with significant morbidity and mortality.1 There are numerous causes and a systematic approach to the initial investigation and management is required. Clinical assessment should start with evaluation of the patient’s degree of hydration, with the measurements of serum and urine osmolality and urinary sodium concentration being the key biochemical investigations. A recent article in this journal highlighted the challenges associated with acute symptomatic hyponatraemia; this article concentrates on the more common scenario of the patient with asymptomatic hyponatraemia.

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Haematological Emergencies on the Acute Medical Take

Clinical Reviews, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

As haematological emergencies are uncommon in daily clinical practice, enhanced awareness and high index of suspicion is required to ensure that the potentially lifesaving measures are offered. This article discusses some of the haematological conditions which may present on the acute medical take.

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Initial Treatment of Pulmonary Embolism

Clinical Reviews, Volume 6, Issue 3, Pages 93 - 136 (2007)

Abstract

Acute pulmonary embolism (PE) is a common presentation on the acute medical take. In our previous article in Vol 6 issue 1 we discussed the diagnostic approach to this condition. This article concentrates on the treatment of PE, including guidance for treatment of PE in pregnancy and cancer. This article also discusses the role of alternative anticoagulants, thrombolysis, surgery and inferior vena caval filters.

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