bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute Hypoglycaemia: Diagnostic criteria, Investigation and Management for the Emergency Physician
Authors:   Diabetes and Endocrinology, Royal Bournemouth Hospital, Dorset, Richardson Tristan , Kerr David ,   Royal Bournemouth Hospital, Bournemouth
Published: June 2021

Hypoglycaemia is a common condition, which may easily be missed due to the variation in clinical presentation in patients with or without diabetes. The most common cause is related to the treatment of diabetes. Non-diabetes related hypoglycaemia is rare. Nonetheless, the need for careful evaluation of the underlying cause is important as well as relieving symptoms. The diagnosis and investigations involved in management of hypoglycaemia are discussed with a direct relevance to the acute general physician.
Management of Tuberculosis for the Acute Physician
Authors:   Physiology, Blackburn Royal Infirmary, Blackburn / Respiratory Medicine, Lancashire Postgraduate Medical School, University of Central Lancashire, Preston, Ormerod L Peter
Published: June 2021

Tuberculosis is increasing world-wide and also in England and Wales, where there are marked geographical and ethnic variations. Acute physicians should be aware of this, and also of the variable manifestations of this multisystem disease, as well as current epidemiology which informs clinical risk stratification. Treatment is highly evidence based, and bacteriological confirmation should be sought whenever possible, partly because of the current level of drug resistance.
Medical Emergencies in Human Immunodeficiency Virus (HIV) Infection
Authors: Rowan David , Henderson Stuart ,   Acute Medicine, University Hospital Southampton Foundation Trust, Southampton
Published: June 2021

With increasing awareness, earlier diagnosis, and aggressive use of anti-retroviral therapy, more people with HIV are living longer so that the average survival time from diagnosis is now significantly better than what it was 10 years ago. As a consequence of this, more patients with HIV are now presenting to hospitals and emergency departments as acute medical emergencies either directly related to their HIV infection, or their treatment.1 An awareness of the potential problems with which these patients can present to hospital, plus guidance on their management is essential to all acute care physicians. In this article we outline the general management of patients with HIV presenting as emergencies to hospital, and then systematically focus on some of the more common clinical problems which may arise.
Cardiac Arrest: recent advances in recognition and management
Authors:   Addenbrookes Hospital, Cambridge, Zaidi Suhail , Senthuran Siva ,   Royal Brisbane Hospital, Australia, Naik Manu ,   Norfolk & Norwich University Hospital, Norwich
Published: June 2021

The features of cardiac arrest will be familiar to any reader who has recently undertaken an Advanced Life Support course. Rather than reproducing algorithms which should be readily available in all UK hospitals, this article emphasises the importance of early recognitions and prevention, and looks at some of the more recent advances in resuscitation technique.
Managing fluid balance in patients with liver disease
Authors:   Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Guha Indra Neil , Sheron Nick ,   Southampton General Hospital
Published: June 2021

A fundamental aspect of managing liver patients in the acute setting is assessing and correcting f luid and nutritional status. The intrinsic abnormalities of salt and water handling in patients with liver dysfunction worsen with disease progression. Additionally, they are further aggravated by the processes that cause decompensation and presentation to hospital e.g. sepsis or haemorrhage. Injudicious use or inadequate use of f luids may create further complications in a patient group with a high mortality and morbidity. We have used a case to help illustrate some of the practical points in managing this group of patients.
Thoracic aortic dissection mistakenly diagnosed as pulmonary embolism: A potentially fatal error
Authors:   Kings Mill Hospital Mansfield Road Sutton in Ashfield Nottinghamshire, Weerasuriya Namal , Jayawardena Manika ,   Kings Mill Hospital Mansfield Road Sutton in Ashfield Nottinghamshire, Snape J ,   Kings Mill Hospital Mansfield Road Sutton in Ashfield Nottinghamshire
Published: June 2021

Thoracic aortic dissection may present in many different ways leading to delayed diagnosis, often with catastrophic results. We present a patient with sudden onset epigastric pain, breathlessness, fever and a left sided pleural effusion, who was initially treated for a chest infection, subsequently for pulmonary embolism, with a serendipitous diagnosis of aortic dissection eventually being made. The strength of association of pleural effusion and aortic dissection and the need for vigilance with regard to the diagnosis of aortic dissection is emphasised.
Simvastatin-induced myositis occurring in a patient with viral hepatitis A
Authors:   Hull Royal Infirmary Anlaby Rd Hull, Shukla Satyen , Anand V
Published: June 2021

A 60 year old female was admitted with jaundice, malaise & loss of appetite. Two weeks before admission she had complained of diarrhoea with abdominal pain. There was no previous history of jaundice, blood transfusion or foreign travel. She denied pruritus, and stools were of normal colour, although her urine was dark. She was non-smoker & did not drink alcohol regularly. She was known to have ischaemic heart disease & hypercholestolaemia and had been taking ramipril 5mg , clopidogrel 75mg, simvastatin 20mg & omeprazole 20mg daily for the previous two years.
Editorial
Authors:   Acute Medicine University Hospital Southampton Foundation Trust Tremona Road Mail Point 520 Southampton SO16 6YD UK, Roseveare Chris
Published: June 2021

As ward round ‘faux-pas’ go, this week’s was a bad one. The patient was a middle aged man with pneumonia – nothing out of the ordinary. Turning to the somewhat hirsute ‘adolescent’ sitting in the chair next to him I asked the question: ‘Are you his son?’, to which the indignant response: ‘No, I’m his wife!’ came as something of a shock. Things went from bad to worse when the house officer helpfully suggested that it was a sign of getting older when you can no longer distinguish the sex of the ‘younger generation’. Not that I needed reminding: I recently reached an interesting milestone, when I realised that that I had once babysat for one of our third year medical students (while she was still in nappies). Having said that, getting older has its compensations – it is now several years since any patient told be I look too young to be a doctor; what’s more, it won’t be long before I have an answer for those sceptics who ask if I will still be doing my job when I am fifty… The first edition of 2005 brings another varied series of review articles. Mark O’Neill follows up his previous paper on bradycardia with a comprehensive account of the management of broad complex tachycardia. Guy Thwaites gives a practical approach to the assessment and treatment of PUO, while Lloyd and Garfield’s review of Non-invasive ventilation helps to demystify this complex subject. For many readers, ‘query urinary tract infection’ will probably stand alongside off legs’ and ‘collapse query cause’ in the ranking of ‘heartsink’ referrals on the medical take. However, if ‘prescribe trimethoprim’ would have been the only two words you would have been able to write on the subject I would commend to you Dr Chaudhuri’s comprehensive account of this topic. A couple of new features appear in this edition. A picture quiz section provides a variation on the case-report theme – no prizes, I am afraid, but you can find the answers on p36. Future submissions of this type, in addition to the standard case report format, are encouraged. Practices in medical admissions units vary widely, and it is important that we share each others’ experiences, both positive and otherwise. To this end I am keen to encourage readers to submit papers describing their activity along the ‘How we do it here…’ theme. To launch this series, Dr Vincent Connolly, winner of the Hospital Doctor Acute Medicine Team of the Year award describes the evolution of his innovative unit in Middlesborough. Finally, the more observant of you may have noticed a subtle change to the title of the journal, with the removal of the CPD Journal prefix to Acute Medicine. Although the educational themes of the journal remain unchanged, it is hoped that this will broaden its appeal beyond consultants and other ‘Points collectors’. I hope this does not detract from your enjoyment of the current and future editions, the reading of which can, as ever, be counted towards your ‘personal’ CPD.
Cardiac Arrhythmias – Part II:Broad Complex Tachycardia . . .
Authors:   Department of Cardiology St. Mary’s Hospital NHS Trust London W2 1NY United Kingdom, O’Neill Mark D , Davies D Wyn ,   Department of Cardiology St. Mary’s Hospital NHS Trust London W2 1NY United Kingdom
Published: June 2021

The acute management of the patient presenting with a broad complex tachycardia is a daunting clinical challenge. A broad complex tachycardia may be ventricular or supraventricular in origin and the ability to interpret correctly the 12-lead electrocardiogram is of critical importance in this differentiation. Broad complex tachycardia should be assumed to be ventricular in origin unless there is compelling clinical and electrocardiographic evidence to the contrary. This article focuses on the immediate diagnosis and management of broad complex tachycardia. In view of the broadening indications for implantation of cardioverterdefibrillator devices (ICD) in the management of ventricular arrhythmias, an approach to the ICD patient presenting to the accident and emergency department with recurrent device discharges is discussed.
Pyrexia of unknown origin
Authors:   Brighton and Sussex University Hospital Eastern Road, Brighton Sussex, BN2 5BE United Kingdom, Thwaites Guy E
Published: June 2021

Classical pyrexia of unknown origin (PUO), defined as fever of >38 oC on several occasions for greater than three weeks despite investigation in hospital (>3 days) or out of hospital (>2 visits), is an uncommon but challenging problem. The incidence and aetiology vary according to the geographic region, the age structure of the population, and the immune status of the patient; alternative definitions of PUO exist for immune compromised individuals. Preliminary investigations should be determined by detailed history and repeated examination. Biopsy of abnormal tissues should be performed early. If uncertainty persists, abdominal computerised tomography (CT), radiolabeled white cell scans, and the Duke endocarditis criteria carry the highest diagnostic yield. Blind bone marrow biopsy is probably only useful in immunocompromised patients.
Non Invasive ventilation for acute respiratory failure
Authors:   St Bartholomew’s Hospital Medical College, Lloyd Richard J , Garfield Mark J ,   Ipswich Hospital NHS Trust Heath Road IP45PD
Published: June 2021

Non-invasive ventilation has become an increasingly utilised tool for the treatment of acute respiratory failure. Potential benefits include a decreased incidence of intubation, duration of hospital stay and mortality. Non invasive ventilation is also being used more and more outside the intensive care environment. Successful use of non invasive ventilation involves knowledge of its indications, contraindications and limitations, and appropriate patient selection. This article reviews these issues as well as the practical application of non invasive ventilation in the acute setting.
Cellulitis or Charcot Neuropathy in Diabetes
Authors:   , Huddersfield Royal Infirmary Calderdale and Huddersfield NHS Trust Huddersfield Royal Infirmary Lindley, HD3 3EA, Mandour Omer , Elyas Salim ,   , Huddersfield Royal Infirmary Calderdale and Huddersfield NHS Trust Huddersfield Royal Infirmary Lindley, HD3 3EA, Cooper Nicola ,   Leeds Teaching Hospitals
Published: June 2021

Cellulitis of the lower limb is a common presentation in patients with diabetes. We report a case illustrating how Charcot neuropathy can be overlooked because of its resemblance to cellulitis.
Sudden Hemiplegia in a young patient
Authors:   Bassetlaw General Hospital Worksop, Nottinghamshire S81 0BD, Kar-Purkayastha S , Krishnaswami J Vachagan ,   Bassetlaw General Hospital Worksop, Nottinghamshire S81 0BD
Published: June 2021

Stroke is more common in older patients; when it occurs in younger persons the causes may be slightly different. If adequately investigated, a cause can be ascertained in significant proportion of younger patients with stroke. Dissection of the internal carotid artery is an important cause of stroke in this age group and probably accounts for about 20% of cases. An association with elevated plasma homocysteine has been previously reported. We report a case of spontaneous internal carotid artery dissection associated with raised plasma homocysteine in a twenty-two year old, previously healthy man.
Picture Quiz: An unusual cause of headache – Answers
Authors:   Hull Royal Infirmary Anlaby Rd Hull, HU3 2JZ, Shukla Satyen , Anand V ,   Hull and East Yorkshire Hospitals NHS Trust
Published: June 2021

The MRI images (see page 27) show lobulated meningeal thickening along the medial aspect of the right middle cranial fossa extending into sylvian fissure, suprasellar cistern, interpenduncular cistern and roof of 4th ventricle which enhanced on postcontrast images. These appearances are diagnostic of metastatic leptomeningeal carcinomatosis.
Cardiac Arrhythmias – Part III Narrow Complex Tachycardia
Authors:   Department of Cardiology, St. Mary’s Hospital NHS Trust, London, Davies DW , O’Neill MD ,   Department of Cardiology, St. Mary’s Hospital NHS Trust, London
Published: June 2021

Narrow complex tachycardia usually refers to an abnormality of cardiac rhythm involving the tissues of the sinus node, atrial tissue, the atrioventricular node or an accessory atrioventricular communication. Although atrial fibrillation is the most common supraventricular arrhythmia, the term “supraventricular tachycardia” conventionally refers to the group of rhythm disturbances encompassing sinus tachycardia (appropriate and inappropriate), atrial tachycardia, atrial flutter, atrioventricular nodal reciprocating tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT) including the Wolff Parkinson White syndrome (WPW). Atrial fibrillation is beyond the scope of this article which focuses on the diagnosis and acute management of the patient presenting with one of these common causes of a regular, narrow complex tachycardia.
Amiodarone – induced pulmonary nodules mimiking metastatic lung disease – investigation by somatostatin radio peptide scaning
Authors:   Department of Respiratory Medicine, St Helier Hospital, Varney Veronica , Warren Mary ,   Department of Radiology, St Helier Hospital, Palmer M ,   Department of Radiology, St Helier Hospital
Published: June 2021

A 61 year old former paramedic presented to A&E complaining of palpitations. He was found to be in atrial fibrillation, which reverted spontaneously to sinus rhythm. A chest x-ray taken at that time showed multiple pulmonary nodules consistent with metastatic malignancy (Figure 1). In the past he had been treated with amiodarone 200mg daily for 6 years following a previous diagnosis of atrial fibrillation, which had been attributed to alcoholic cardiomyopathy. He had discontinued the drug 8 months earlier, after selfdiagnosing hypotension and bradycardia. A previous chest X-ray, taken before starting amiodarone, was normal.
Deep vein thrombosis assessment clinic: Evaluation of a new working practice
Authors:   Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Singh MK , Tonks KG ,   Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Langford Nigel J ,   Acute Medicine and Clinical Pharmacology and Therapeutics, City Hospital, Birmingham, Wingate JP ,   Radiology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Lee Brian C ,   Acute Medicine, Diabetes and Endocrinology Medical Assessment Unit, Sandwell and West Birmingham Hospitals NHS Trust, Dudley Road, Birmingham
Published: June 2021

Suspected deep vein thrombosis (DVT) is a common reason for medical referral to hospital. We evaluated our new approach to assessment of DVT using combined automated strain gauge plethysmography and pretest probability score in comparison with venous ultrasonography in 100 consecutive patients with suspected DVT referred to the nurse-led clinic. The combined plethysmography and pretest probability score produced a negative predictive value of 99%, positive predictive value 53%, sensitivity 94% and specificity 83% for detection of a DVT. We conclude that our new working practice for DVT assessment is both safe and cost effective and can lead to a reduction in venous ultrasonography of approximately 70%.
Should physicians manage hip fractures?
Authors:   Royal Bournemouth Hospital, Bournemouth, Sixsmith Clare , Poulton Sue ,   Elderly Medicine, Queen Alexandra Hospital, Portsmouth
Published: June 2021

Elderly People with hip fractures are among the most frail and medically complex of all hospital inpatients. In one sense, the fracture itself is merely a marker of frailty, and many of these patients would have found themselves on an acute medical ward if they had not broken a bone. Despite this, many centres still expect the orthopaedic team to manage these cases with only token input from physicians. This article explores other models of care for elderly hip fracture patients and looks at the evidence base to support the proposition that physicians should be managing hip fractures.
Controversies in the management of life
Authors:   Anaesthesia and Intensive Care Medicine, Norfolk and Norwich University Hospital NHS Trust, Norwich, Dixon JM , Innes NJ ,   Respiratory Physiology, Ipswich Hospital NHS Trust, Ipswich
Published: June 2021

Asthma has a complex aetiology with many precipitating factors leading to a final common pathway of airway inflammation and bronchospasm. Patients with asthma are at risk of developing acute exacerbations. A subgroup of these patients develop severe exacerbations. This review will focus on some of the issues in the management of adults with life threatening asthma that remain controversial.
Picture Quiz: Abdominal Pain in a patient receiving low molecular weight heparin
Authors:   Genito-Urinary Medicine, Leicester Deanery, Leicestershire, UK, Nandy U , Varughese GI ,   ASCOT Centre, City Hospital, Birmingham/ Endocrinology, West Midlands Deanery, Iqbal N ,   Endocrinology, Trent Deanery, Nottinghamshire, Constable TJ ,   Manor Hospital, Walsall
Published: June 2021

A 63 year old lady with known ischaemic heart disease was admitted to hospital with cardiac sounding chest pain. Blood pressure was 161/80 on admission, and full examination was unremarkable. ECG showed ischaemic changes in the inferior leads, and a diagnosis of unstable angina was made. Troponin I was undetectable. She was treated with subcutaneous Enoxaparin 1.5mg/kg and an intravenous nitrate infusion. Her pain settled the following day, allowing the nitrate infusion to be weaned off, although the Enoxaparin treatment was continued, pending a cardiology opinion. On the third day after admission she collapsed on the ward with a blood pressure of 95/59mmHg; examination revealed lower abdominal tenderness with a mass in the right iliac fossa. Blood tests showed that her haemoglobin had dropped by 5 grams/decilitre, she underwent urgent abdominal ultrasound followed by CT (see below).
Picture Quiz (Answer)
Authors:   Genito-Urinary Medicine, Leicester Deanery, Leicestershire, UK, Nandy U , Varughese GI ,   ASCOT Centre, City Hospital, Birmingham/ Endocrinology, West Midlands Deanery, Iqbal N ,   Endocrinology, Trent Deanery, Nottinghamshire, Constable TJ ,   Manor Hospital, Walsall
Published: June 2021

Subcutaneous low molecular weight heparins are widely used in hospitalised patients for the treatment of DVT, pulmonary embolism and acute coronary syndromes, as well as for thromboprophylaxis. Rectus sheath hematoma is a recognised, but sometimes misdiagnosed, complication of treatment with anticoagulant therapy,1 including full and prophylactic doses of low molecular weight heparin.2 Studies have shown that the most frequent location of a haematoma is in the lower part of the abdomen. The explanation for this lies in the anatomy of the abdominal wall.3 The rectus abdominis muscle lies between the aponeuroses of the transverse and oblique muscles, which form the so-called rectus sheath. In this lower aspect of the muscle the perforating branches of the inferior epigastric artery running in the preperitoneal fat may rupture causing a large haematoma widely spreading in this loose space. Care should be taken to avoid this area for injection of heparin, particularly in thin patients where inadvertent intramuscular.
Management of Acute Ischaemic Stroke
Authors:   Consultant Geriatrician Queen Alexandra Hospital Cosham Portsmouth PO6 3LY, Jarrett David , Dave Hemang ,   Royal United Hospital Bath
Published: June 2021

National audits of stroke care in the UK have repeatedly shown deficiencies in basic care. The key to good care is prompt thorough assessment, investigation and management of physiological parameters i.e blood pressure, glycaemia, temperature and oxygenation. Three interventions are of proven benefit in acute ischaemic stroke: admission to an organised stroke service, early aspirin and intravenous thrombolysis. The use of multidisciplinary guidelines and education and audit around these improves care.
Recognition and Early Management of Acute Liver Failure
Authors:   Institute of Liver Studies Kings College Hospital Denmark Hill London SE5 9RS, Berry Philip , Wendon Julia ,   Institute of Liver Studies Kings College Hospital Denmark Hill London SE5 9RS
Published: June 2021

Acute liver failure (ALF) is a rare but frequently devastating condition, with the potential to disable virtually every organ and system in the body. However, if it is recognised swiftly, and if its specific complications are managed actively, a good outcome can be achieved, especially in the young. The first hours are crucial in stabilising the patient, optimising metabolic and cardiovascular parameters, and reducing the risk of permanent neurological injury or brain death. Simultaneous liason with a specialist unit will allow a planned, safe transfer and access to definitive treatment such as liver transplantation, should the patient require it. This review highlights the clinical and laboratory features of ALF, emphasises aspects of early treatment which will aid short term survival, and makes recommendations concerning safe transfer to a liver unit. Information is also given to aid early counselling of relatives and next of kin.
Emergency Management of Phaeochromocytoma
Authors:   Royal Free Hospital Pond St London NW3 2QG, Solomon Andrew , Bouloux Professor Pierre ,   Royal Free Hospital Pond St London NW3 2QG
Published: June 2021

Phaeochromocytomas are catecholamine secreting tumours associated with unpredictable patterns of hypertension. A variety of forms of investigation are available for detecting hypersecretion of catecholamines or their metabolites. Recent developments in the biochemical diagnosis, localisation and management of phaeochromocytoma and its associated crisis are reviewed.
Making Sense of the Chest X-ray, a hands-on Dr Paul Jenkins, Hodder Arnold Press 2005
Authors:   Department of Cardiothoracic Radiology Southampton University Hospitals NHS Trust Tremona Road Southampton SO16 6YD, Sundaram Sangeetha , Harden Stephen ,   Department of Cardiothoracic Radiology Southampton University Hospitals NHS Trust Tremona Road Southampton SO16 6YD
Published: June 2021

The chest radiograph is one of the most challenging images to interpret reliably, yet accurate film reading can be very rewarding professionally and can significantly improve patient management. These skills are important for all professionals working in acute medicine and acquiring them requires a comprehensive book collection and a wide experience but above all a good teacher.
Emergency Management of Acute on Chronic Liver Disease
Authors:   University Hospital Bristol, U.K., Portal AJ
Published: June 2021

Chronic liver disease is becoming more common in the UK. There has been much media coverage due to recent change in licensing laws and celebrity figures suffering from cirrhosis. This review highlights the common complications of cirrhosis that frequently present to the acute physician, focussing on initial presentation and subsequent management, based on the current best available evidence.
Management of Acute Complications Associated with Sickle Cell Disease
Authors:   Brighton and Sussex University Hospitals NHS Trust Eastern Road Brighton, Corbett Tim , Howard Jo ,   Middlesex Hospital Acton Lane Park Royal London
Published: June 2021

Sickle cell disease is the commonest haemoglobinopathy within the United Kingdom.1 Although the majority of patients will present to hospitals within major cities, this is not invariably the case. It is therefore important that all physicians on acute medical take are familiar with the acute management of sickle cell disease. This review encompasses the initial management which is subdivided into analgesia, investigations and supportive care. In addition the more severe complications of sickle cell, including the acute chest syndrome and stroke are covered. It should be remembered that close collaboration is required with the haematology department, particularly in those patients with respiratory distress or stroke, so that prompt arrangements can be made if exchange transfusion is required.
Psoas Abscess: Diagnosis and Treatment
Authors:   King’s Mill Hospital Mansfield Road Sutton in Ashfield Notts, Kandasamy Raj , Srikanth Asha ,   King’s Mill Hospital Mansfield Road Sutton in Ashfield Notts, Rutter SM ,   King’s Mill Hospital Mansfield Road Sutton in Ashfield Notts, Butcher CJ ,   King’s Mill Hospital Mansfield Road Sutton in Ashfield Notts, Snape J ,   King’s Mill Hospital Mansfield Road Sutton in Ashfield Notts
Published: June 2021

Psoas abscess is an uncommon presentation on the acute medical take. However recognition and appropriate treatment is essential. This review is designed to highlight the clinical features, microbiology, diagnostic tests and treatment for this condition. In order to illustrate some of the pitfalls and complexities in the management of psoas abscess we have included a case history of a patient who was recently treated in our department.
Spontaneous Splenic Rupture in a Patient with Pneumonia and Sepsis
Authors:   North Tyneside General Hospital, Athey Richard , Barton Lorna ,   Royal Victoria Hospital, Newcastle, Horgan Liam ,   North Tyneside General Hospital, Wood Brian ,   North Tyneside General Hospital
Published: June 2021

We present the case of a patient who presented with evidence of pneumonia, sepsis and anaemia but no significant abdominal signs. A routine abdominal ultrasound scan revealed evidence of spontaneous splenic rupture. He underwent splenectomy but passed away subsequently from respiratory complications. The many associations of spontaneous splenic rupture are discussed. The diagnosis should be considered in any patient presenting with shock and non-specific abdominal signs and in those with pre-existing conditions known to cause splenomegaly.
Intra-Pericardial Rupture of Bacterial Hepatic Abscess: An Unusual Cause of ‘Cardiac’ Chest Pain
Authors:   Norfolk and Norwich University, Kumar Dhananjay , Zaidi Suhail M ,   Norfolk and Norwich University, Jenkins Paul F ,   Norfolk and Norwich University
Published: June 2021

We report a rare case of bacterial pericarditis secondary to rupture of liver abscess into the pericardium. The patient presented with cardiac-sounding chest pain and with normal ECG, CXR and Troponin-I assay. The initial echocardiogram showed minimal pericardial fluid but, when he later developed overt clinical signs of cardiac tamponade, a CT scan of chest and abdomen revealed a pronounced pericardial effusion. It also revealed an abscess located in the left lobe of liver and this had apparently ruptured into the pericardial sac. Culture of the purulent pericardial aspirate grew Proteus and Enterococcus; these organisms have been reported only rarely as responsible for causing purulent pericarditis. The patient was treated initially by emergency ultrasound-guided pericardiocentesis; later he required thoracotomy and pericardiectomy in order to manage persistent re-accumulation of pus in the pericardium.
The Management of Diabetic Ketoacidosis
Authors:   Department of Diabetes and Endocrinology Oxford Children’s Hospital Oxford OX3 9DU, Edge JA , Hammersley MS ,   Consultant Physician and Acute Care Diabetologist Senior Clinical Lecturer Nuffield Department of Medicine John Radcliffe Hospital Oxford OX3 9DU
Published: June 2021

This article reviews the management of diabetic ketoacidosis (DKA) in adults with a focus on the three basic principles of treatment: intravenous fluid therapy, intravenous insulin administration and potassium replacement. The recommendations are modelled on the national guidance for the management of DKA in children. We highlight the importance of being alert to signs of life-threatening complications of the condition such as cerebral oedema and adult respiratory distress syndrome (ARDS). We also discuss the use of near-patient testing of capillary beta-hydroxybutyrate (b-OHB) using a ketone meter as an aid to managing and preventing DKA.
A Review of the Evaluation and Management of Syncope in the Acute Medical Unit
Authors:   Queen Alexandra Hospital Portsmouth PO6 3 LY, Butler Sean , Bacon MTF ,   Queen Alexandra Hospital Portsmouth PO6 3 LY, Brickwood Anne ,   Wythenshawe Hospital Manchester M23 9LT, Wood Emma ,   Queen Alexandra Hospital Portsmouth PO6 3 LY
Published: June 2021

Syncope is a common acute presentation and frequently results in hospitalisation. Cardiac syncope is potentially life threatening. The diagnosis and management of syncope demands a careful history, witness account wherever possible, and a comprehensive assessment. This, in combination with routine investigations, will provide an answer in a significant percentage of patients.
Alcohol Related Non-traumatic Rhabdomyolysis and Compartment Syndrome
Authors:   Department of Gastroenterology/General Medicine Singleton Hospital Sketty Lane Sketty Swansea SA2 8QA, Ong JPL , Thomas LA ,   Department of Gastroenterology/General Medicine Singleton Hospital Sketty Swansea SA2 8QA.
Published: June 2021

Rhabdomyolysis is a serious and life-threatening condition in which skeletal muscle is damaged, commonly resulting in acute renal failure. The causes of this clinical entity can be traumatic and non-traumatic. In the latter group, alcohol is the commonest cause. This report describes the case of a 25 year old man who presented with rhabdomyolysis leading to acute renal failure after an alcohol binge. He presented with painful legs and lower extremity compartment syndrome. The patient recovered with surgical fasciotomy and renal support. This case illustrates the importance of early recognition and treatment of alcohol related non-traumatic rhabdomyolysis and compartment syndrome.
Picture Quiz: A Case of Sudden Severe Chest Pain: Answers
Authors: Stivaros. S M , Sullivan P ,   Hope Hospital. Salford, Rabia Mustafa Abu ,   Hope Hospital Stott Lane. Salford Manchester M6 8HD
Published: June 2021

Pneumomediastinum is a condition in which air presents in the mediastinum. It was first described by Laennec in 1819 as a consequence of trauma. Spontaneous pneumomediastinum (SPM) was reported in 1939 by Hamman.
Summary of Breakout Sessions
Authors:   Halifax, Scriven Nick , Skene Hannah ,   Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH
Published: June 2021

Breakout Session 1: “ Novel Approaches in Acute Medicine” Breakout Session 2: Acute Medicine Training
Halifax: A Trainee’s perspective
Authors:   Acute Medicine Queen Alexandra Hospital Portsmouth, Banfield Abigail
Published: June 2021

I have never been compelled to summarize my thoughts on a society meeting before, except in a social context…. but the Spring meeting piqued my interest on a number of levels, and that’s got to be a first for me.
Cerebral Venous Sinus Thrombosis
Authors:   Wessex Neurological Centre, Southampton General Hospital, Tremona Road, Southampton, Lovett Joanna K , Pinto Ashwin ,   Neurology, Southampton University and Portsmouth Hospitals
Published: June 2021

Cerebral (or dural) venous sinus thrombosis (CVST) is a condition distinct from other cerebrovascular disease, which presents its own particular diagnostic difficulties and treatment controversies. The clinical presentation is variable and may mimic a wide range of other neurological disorders that include subarachnoid haemorrhage, encephalitis, eclampsia, idiopathic intracranial hypertension and arterial stroke.
Management of Acute Atrial Fibrillation
Authors:   Cardiology, Eastbourne District General Hospital, East Sussex NHS Trust, Taggu Wasing , Rathore V S ,   Cardiology, Eastbourne District General Hospital, East Sussex NHS Trust
Published: June 2021

Atrial fibrillation (AF) is the most common cardiac arrhythmia; despite many available guidelines the optimal management strategy remains elusive. The most common presentations of acute AF are palpitations, breathlessness, syncope, dizziness, chest pain, transient ischaemic attack (TIA) and stroke. Patients may need urgent electrical cardioversion (ECV) or pharmacological cardioversion (PCV) and long term anticoagulation therapy. This review aims to discuss some issues surrounding the early management of acute AF in the Acute Medical Unit.
Tuberulous Meningitis masked by Temazepam Overdose
Authors:   Department of General Medicine and Intensive Care, John Radcliffe Hospital Oxford, Oxfordshire, Rajendram Rajkumar , Jennings Adrian ,   Department of Anaesthesia, University Hospital Birmingham NHS Trust, Selly Oak Hospital, Birmingham, Ehtisham Javed ,   Department of General Medicine and Cardiology, Milton Keynes General Hospital, Milton Keynes
Published: June 2021

A 47 year old Chinese businessman was found unconscious at home following an overdose of 280 mg temazepam. He was found by his sister who had visited because he had not returned her telephone calls for several weeks. He had been resident in England for 8 years but returned to Hong Kong frequently. Since his last visit to Hong Kong, 4 months previously, his mood had been low and he had developed anorexia, weight loss and insomnia. Physical examination and routine investigations were unremarkable and a diagnosis of depression was made. Citalopram 10 mg daily and temazepam 10 mg daily had been prescribed one day prior to admission.
Occult Bilateral Hip Fracture Secondary to Seizure: A Case Report and Literature Review
Authors:   General Medicine, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Fingleton J
Published: June 2021

Seizures are a common presenting complaint in acute medicine and post-ictal patients can pose a diagnostic challenge. Approximately 1% of patients presenting after a seizure will have sustained a fracture. Delayed diagnosis is common and can lead to worse functional outcomes. A case of occult bilateral neck of femur fracture secondary to seizure is presented together with a review of the literature.
An Unusual Cause of Pancytopaenia
Authors:   Department of General Medicine, John Radcliffe Hospital Oxford, Acton Louise , Chakraborty Arup ,   General Internal Medicine (Oxford Deanery) and Intensive Care Medicine (London Deanery), Thomson David ,   Department of General Medicine, John Radcliffe Hospital Oxford, Wass John ,   Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital Oxford
Published: June 2021

A 76-year-old man was admitted to the acute medical take with a long history of tiredness. He described slowed thinking, constipation, aching thighs, dry skin, a hoarse voice, hair loss and 10 kilograms of unintentional weight loss. He had lived in Spain for 7 years and his daughter had persuaded him to return to the UK for a medical check-up.
Improving Local Practice of Venous Thromboembolism Prevention in Medical Patients
Authors:   Acute Medicine, Scunthorpe General Hospital, Scunthorpe, North Lincolnshire, Irvine NJ , Paterson John ,   Division of Medicine, Scarborough Hospital
Published: June 2021

Venous thromboembolism has long been recognised as a potentially avoidable cause of significant morbidity and mortality in hospitalised patients. With national recommendations awaited there have been clear instructions from the department of health that steps need to be made at a local level to increase awareness and address the problem prior to the expected completion of the NICE guidelines in 2007. We demonstrated an improvement in the prescription of thromboprophylaxis following implementation of simple and inexpensive changes in our department.
Initial Treatment of Pulmonary Embolism
Authors:   Chelsea & Westminster Hospital 369 Fulham Road London SW10 9NH, Proudfoot Alastair , Yarranton Helen ,   Addenbrookes Hospital Cambridge, Gibbs Simon ,   Addenbrookes Hospital Cambridge, Bell Derek ,   Northwest London Chelsea and Westminster Hospital Imperial College London Fulham Road London SW10 9NH
Published: June 2021

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.
Managing Pleural Disease in Acute Medicine (I): Pleural Effusion
Authors:   James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, Lone Nazir I. , Antunes George ,   James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW
Published: June 2021

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.
A case of orthodeoxia platypnoea in a patient with adult polycystic kidney and liver disease with a patent foramen ovale
Authors:   Southwold House 3 Bowers Lea Cam Dursley Gloucestershire GL11 5PR, Graves Jennifer , Mason Martina ,   Southwold House 3 Bowers Lea Cam Dursley Gloucestershire GL11 5PR, Laws Diane ,   Royal Bournemouth Hospital Castle Lane East Bournemouth, Dorset, BH7 7DW
Published: June 2021

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.
Prescribing at the coalface in the era of antimicrobial resistance
Authors:   University Hospitals Southampton NHS Foundation Trust, Lillie Patrick , Barlow Gavin
Published: June 2021

Antimicrobial resistance is of increasing concern to patients, physicians and policy-makers alike. The challenge for the clinician at the coalface, however, is to avoid the undertreatment of seriously ill patients whilst minimising the evolution of antimicrobial resistance. Difficult decisions about the most appropriate antibiotic to prescribe can be supported by careful risk factor and prognostic assessment.
Management of Exacerbation of COPD
Authors:   Heatherwood and Wexham NHS Trust Chest Clinic King Edward VII Hospital St Leonard’s Road Windsor, Russell Richard , Biswas Nandini ,   ing Edward VII Hospital St Leonards Road Windsor
Published: June 2021

COPD is a progressive debilitating lung condition the clinical course of which is punctuated by acute severe increases in symptoms (exacerbations). These can be life threatening and are a considerable cause of morbidity and mortality as well as frequently requiring hospital admission. The aims of treatment are to prevent attacks through vaccination, smoking cessation, appropriate medication, the provision of pulmonary rehabilitation and also patient education. During an attack treatment should be provided in the most suitable place for the individual (home or hospital) and consists of an accurate diagnosis, clinical assessment and the provision of bronchodilators, corticosteroids and antibiotics where appropriate. More severe attacks necessitating hospital assessment and admission may require ventilatory support and even intensive care. Where possible patients should be involved in decision making, particularly with regard to treatment and a possible ceiling of care.
Cocaine abuse: acute medical manifestations & current recommended management strategies
Authors:   Scunthorpe General Hospital Scunthorpe North Lincolnshire, Irvine NJ , Penston J ,   Scunthorpe General Hospital Scunthorpe North Lincolnshire
Published: June 2021

Recreational cocaine use in the UK is steadily rising. This review summarises some of the common clinical manifestations of cocaine use which may be encountered by acute physicians and discusses the available treatment options.
Osteomyelitis as the cause of acute leg pain on the MAU
Authors:   Royal Cornwall Hospital, Truro, Cornwall, Mascas Ramona , Evans Kate ,   Plymouth Hospitals NHS Trust Derriford Hospital, Derriford Road, Plymouth. UK, Browne Duncan ,   Royal Cornwall Hospital, Truro, Cornwall
Published: June 2021

An acutely painful swollen leg is a common presentation to Medical assessment units, typically secondary to cellulitis or deep vein thrombosis, although alternative diagnoses should to be considered in the presence of atypical features or inconclusive investigations.
A Case of Fatal Felodipine Overdose
Authors:   Imperial College Healthcare NHS Trust, Department of Medicine, Lota Harpreet , Powell Natalie ,   Surrey and Sussex Healthcare NHS Trust, Negus Rupert ,   Royal Free London NHS Foundation Trust, Leonard Richard ,   Imperial College Healthcare NHS Trust, Department of Medicine, Manikon Maribel ,   Imperial College Healthcare NHS Trust, Department of Medicine
Published: June 2021

A 54 year gentleman was admitted to hospital within four hours of taking an overdose of modified release felodipine tablets, with a total dose of approximately 250 mg. The initial management comprised fluid resuscitation, calcium chloride and glucagon. He remained hypotensive and was commenced on hyperinsulinaemia-euglycaemic therapy. Hypotension persisted with the development of progressive metabolic acidosis despite increasing inotropic support, haemofiltration and high dose insulin-dextrose infusions. The patient died 60 hours post overdose. The case highlights the profound, refractory circulatory collapse and lethal consequences of significant calcium channel blocker overdose and also reviews potential management strategies to attempt to reverse these changes. Despite the lack of evidence of whole bowel irrigation in overdose per se, its role in the removal of modified release compounds has not been studied. We would strongly urge emergency departments to consider this therapeutic modality, especially in overdoses involving delayed release preparations of calcium channel blockers, which are extremely toxic in overdose and are associated with very high mortality.
Stroke due to Thromboembolism from Congenital Aneurysm of Ventricular Septum
Authors:   Royal Gwent Hospital Cardiff Road Newport, Sharma Shashank , Thomas Ajit ,   Glan Clwyd Hospital, Baghomian Aram ,   Glan Clwyd Hospital, Waterfield Nick ,   Glan Clwyd Hospital
Published: June 2021

We describe the case of a 46-year-old female who presented with recurrent episodes of cerebrovascular events. She had an unremarkable family history and no risk factors for stroke, apart from smoking. A transthoracic echocardiogram with ‘bubble’ contrast was normal. However transoesophageal echocardiography demonstrated an aneurysm of the membranous part of the ventricular septum, representing the likely source of thrombo-embolisation. This case highlights the need for a systematic and rigorous approach to the investigation of young patients with stroke.
Acute Medicine and Emergency Medicine are not (Yet?) The Same
Authors:   Heartlands Hospital Birmingham, Gallitelli Mauro , Fabris Elisabetta ,   Princess Royal University Hospital Farnborough Ken, Sabbà Carlo ,   University of Bari Italy
Published: June 2021

The acquisition of “Level 3” competencies in the setting of the Emergency Room from StR in Acute Medicine raises the question of the boundaries and competences of Acute Medicine and Emergency Medicine. The possibility that phisycians with a training both in Emergency Medicine and Acute Medicine will be involved in the management of Emergency Admission Units and Emergency Medicine Departments in the future is herein considered.
Acquired haemophilia – A diagnosis not to be missed
Authors:   Care of the Elderly Department, Queen Elizabeth Hospital King’s Lynn, Norfolk, Kitson S J , Grigoropoulos N F ,   Haematology Department, Queen Elizabeth Hospital King’s Lynn, Norfolk
Published: June 2021

Acquired haemophilia is a rare, life threatening bleeding disorder characterised by the development of auto-antibodies to coagulation factor VIII. Diagnosis is based upon the clinical history of mucocutaneous haemorrhages combined with a selective prolongation of the APTT. The condition is associated with a wide range of conditions, such as autoimmune diseases , solid and haematological malignancies. Treatment involves controlling the bleeding manifestations and eliminating the inhibitor antibodies. Three cases from our recent practice are used to highlight the variable severity of this condition.
Inclusion body myositis a clinical review with illustrative case report
Authors:   Geriatric Medicine, Royal Hampshire County Hospital, Winchester, Deshmukh Sangeeta , Malik Naveed ,   Medicine and Elderly Care, Southampton General Hospital, Southampton, Katifi HA ,   Wessex Neurological Centre, Southampton General Hospital, Southampton, White Gayle ,   Medicine and Elderly Care, Southampton General Hospital, Southampton
Published: June 2021

Every acute physician has come across elderly patients presenting with muscle weakness and falls. Distinction between normal age related muscle wasting and pathological muscle atrophy can be difficult. It is important for acute physicians to be aware of the differential diagnosis of such a presentation. Inclusion body myositis(IBM) is the most common type of acquired myopathy above the age of 50.1 This article aims to highlight the diagnosis and management of this chronic illness. It is frequently misdiagnosed as polymyositis and wrongly treated with steroids.3 The typical symptoms and signs are illustrated by a recent case which presented to our department (see box 1).