Foundation Years Clinical Case Database
The Foundation Years Clinical Cases Database is a selection of 600 clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.
The database covers 33 medical specialties, including A&E, Acute Medicine, Psychiatry, Neurology, Ophthalmology, Acute Medicine, Anaesthesia, Obstetrics and Gynaecology, Surgery, and many more. The Foundation Years Clinical Case Database can be used to support Junior Doctors in building their Foundation Year e-portfolio.
It is a unique product both by its breadth and its focus on Foundation Years Doctors' training: it is the only database written according to the MMC curriculum.
The Foundation Years Clinical Cases Database is fully searchable, or can be browsed by medical specialty. Abstracts can be read free of charge, however a subscription is required in order to read the complete cases.
All articles of the Foundation Years Clinical Cases Database have been peer-reviewed by senior doctors.
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- Bacterial meningitis
A 20 year old male is brought to the emergency department with a one day history of headache, fever and drowsiness. On examination, he is toxic looking, febrile, photophobic, and has neck stiffness. There is no evidence of a skin rash, and no focal neurological deficit is found. How would you assess and manage his presenting condition?
- Septic shock
An 83 year old man is brought to the resuscitation room from a nursing home following the acute onset of confusion, which has progressed to a depressed level of consciousness. He is found on arrival to have a heart rate of 130 bpm, blood pressure of 70/40 mm Hg, respiratory rate of 30/minute, capillary refill time of 6 seconds, temperature of 38.7 degrees Centigrade, and arterial oxygen saturation on room air of 89%. His Glasgow coma score is 13/15. He is known to have hypertension, ischaemic heart disease and Type 2 diabetes mellitus. How would you proceed to manage his presenting condition?
- Practical procedures involved in managing epistaxis
A 65-year-old female presented to the A&E department with epistaxis from her left nostril lasting for 45 minutes. She had tried to control the bleeding by pinching the bridge of her nose but to no avail.
- Can this adult who has sustained a head injury go home?
A 24-year-old man attended his local A&E department in the early hours of the morning after being assaulted. He was accompanied by his friend who had witnessed the incident. They gave a history of the patient being attacked while leaving a pub. He was knocked to the ground and received repeated blows to the face and head. His GCS was 14/15 on arrival in the A&E department. Prior to the assault, he was fit and well and was not taking any medication, prescribed or otherwise.
- Managing accidental childhood burns
We present a case based discussion of a fire year old boy who attended the Accident and Emergency department with 18% surface area of burns following a household accident. It highlights the key elements of assessment in paediatric resuscitation and the principles of management of burns in children. We look at the criteria for referral to a tertiary centre and the safeguarding issues that can arise from cases of paediatric injury.
- Wound management and suturing
An 82-year-old woman presents to the Emergency Department (ED). She fell against a door and has sustained a laceration to the dorsum of her left hand.
- Principles of wound care in the Emergency Department
A seventy-nine year old female patient fell onto a garden cane which penetrated the right side of her face. The management, radiological investigation, anatomy of the injury and complications are presented as the basis for a Case Based Discussion.
- Management of chest trauma in the Emergency Department
A 48 year old man was brought to the Emergency Department by airambulance after colliding into a cliff face whilst paragliding; he had then fallen a further 5 feet to the ground. The pre-alert call to the Emergency Department suggested he had sustained significant thoracic injuries.
- Pelvic fracture management
Following a high speed road traffic accident a patient is airlifted to hospital where the trauma team are assembled. The case is used to illustrate the management of high energy pelvic injuries, and the management of major haemorrhage in this context. Low energy pelvic injures are not considered.
- Urological emergencies
A 58-year-old patient (smoker) is admitted to the Emergency Department by his GP with severe right-sided loin pain radiating into the right lower abdomen.
- Local anaesthetics and their uses in Emergency Medicine
The concept of local anaesthesia was first introduced by the ophthalmologist Carl Koller in 1884 in conjunction with his work with Sigmund Freud on the systemic and local effects of cocaine. The concept of regional anaesthesia was introduced by William Halstead the following year. At the turn of the century Einhorn introduced the local anaesthetic procaine which remained the drug of choice until the introduction of lidocaine (lignocaine) in 1943. In 1973 bupivacaine, a longer acting local anaesthetic, was added to the growing list of available agents. Local anaesthetics produce safe and effective analgesia in a wide variety of clinical settings from the simple insertion of a venous cannula to a femoral nerve block in the trauma patient. The mode of action of local anaesthetics is to reduce membrane permeability to sodium. They act firstly upon small unmyelinated C fibres, thus pain and temperature are the first sensory modalities to be affected. Doctors of all specialities must therefore be fully aware of the agents available, the techniques described and safety issues with regard to avoiding local anaesthetic toxicity.
- Anaphylaxis
A 17 year old male is brought to the resuscitation room shortly after inadvertent ingestion of a sandwich containing traces of peanut butter. On arrival, he is agitated and acutely short of breath, with a blood pressure of 80/60 mm Hg, a heart rate of 120 beats per minute, and respiratory rate of 26/minute. He has evidence of generalised urticaria, and auscultation of the lungs reveals widespread wheezing bilaterally. His oxygen saturation is 90% on room air. How would you proceed to manage him?
- Assessment of acid-base balance
A 43-year-old woman presents to the emergency department with diarrhoea and vomiting. She is under regular follow-up of the renal department due to Stage 4 Chronic Kidney Disease (CKD). The cause of her renal disease was autosomal dominant polycystic kidney disease and her last creatinine level in the clinic was 280mmol/L (estimated GFR = 17 ml/min/1.73 m^2)
- Gout: treatment and renal complications
A 68-year-old gentlemen presented to A&E with a 1-week history of being “off his legsâ€. On examination he was drowsy and febrile. He was admitted and treated for a urinary tract infection as he had a neutrophilia and the presence of blood and protein in his urine. In the past, he had been treated for hypertension, a stroke and non-specific c arthritis. Over the 5 days subsequent to admission, he developed oedema, severe hypoalbuminaemia and proteinuria and his C-reactive protein (CRP) rose to over 500. Blood cultures came back negative for organisms. It was noted that asymmetrical synovitis and bilateral knee and shoulder effusions had developed. Joint aspiration revealed negatively birefringent crystals and no organisms were seen or cultured. Tophi were noted on his pinnae and distal interphalangeal joints. A diagnosis of acute polyarticular gout with associated nephrotic syndrome was made. He received colchicine orally and underwent arthroscopy and lavage of his knees and shoulders. His symptoms and nephrotic syndrome resolved and he was discharged on regular allopurinol. He recovered well after a period of rehabilitation in a community hospital.
- A case of acidosis
A 59-year-old male presented to the resuscitation room of the emergency department with a gradual onset of shortness of breath over the preceding 2 days. There was no associated chest pain, cough, haemoptysis, fever or other symptoms. A past medical history of type 2 diabetes mellitus, hypertension and hypercholesterolemia were noted. At the time of attendance, he was on metformin, gliclazide, an ACE inhibitor and a statin.
- Non-accidental injuries in children
Non-accidental injuries (NAI) are not uncommon in children and can present in many different clinical settings. Although the majority of children with suspected child abuse are referred to paediatricians with skills in child protection, many children with possible NAI may present to other specialties such as general practice, accident and emergency, orthopaedics, general surgery, psychiatry as well as to dental practices.
- Subdural haematoma
A 79-year-old man is brought into the Accident and Emergency department by his son after sustaining a head injury during a fall 2 hours previously. He has been increasingly confused and unsteady on his feet. On examination, he appears drowsy with a right sided hemiparesis and an ipsilateral dilated pupil. How would you assess and manage his condition?
- Recognising and managing stridor
A 52-year-old lady presents to the accident and emergency department with acute onset of difficulty in breathing, very painful swallowing with drooling and fever.You examine her to fit nd she has harsh high-pitched noisy breathing. The noise only occurs in the inspiratory phase of the respiratory cycle. She is virtually aphonic. Her temperature is 38.4°C, respiratory rate is 30 breaths per minute, and oxygen saturation on room air is 90%.
- Practical management of epistaxis
A 75-year-old man presents to the emergency department with nose bleeding that started 1h previously and is not stopping. There is no history of trauma. He is on warfarin because of atrial fibrillation.
- Acute facial burning
A 64-year-old man attended the emergency department 2h after the sudden onset of a burning sensation on the left side of the face. Three hours later, while being discharged from the hospital emergency department, it was noticed that he had developed a hoarse voice and dysphagia for both liquids and solids. His past medical history included hypertension, type 2 diabetes mellitus and ischaemic heart disease.
- Sudden onset epigastric pain
This article outlines a case of epigastric pain presenting to Accident & Emergency. Questions supported with short and long answers aim to challenge the reader to consider certain aspects of patient management and the associated diagnostic challenges.
- Emergency oxygen use in adults
Oxygen is perhaps the most commonly used and under recognised drug in patients presenting with medical emergencies. Most trainees who look after acutely unwell patients will have some experience of patients suffering the adverse effects of over or under use of oxygen, yet few of us ever prescribe it. Why then are we so poor at prescribing this particular drug, when we recognise the correct prescription of other therapeutic agents as one of "the essentials" of medical care? Despite its importance, the physiology of oxygen delivery (and consequently the pathophysiology of impaired oxygen delivery) is not always fully understood by many medical staff. As junior doctors we tend to receive conflicting advice from more senior colleagues (especially from differing specialties), who often have very strong ideas about the administration of oxygen, despite a relative lack of randomised controlled trials on which to base them.
- Triage in the Emergency Department: Sepsis
Triage in the Accident and Emergency (A&E) department is the first step for any patient admitted to a hospital. Baseline observations help to identify critically ill patients and facilitate an urgent assessment with treatment via calculation of the Modifid Early Warning Score (MEWS). The higher the score, the more urgent attention is required from a doctor. In this article we outline the Surviving Sepsis Campaign 2008 (SSC) guidelines. Additionally, the key steps in management of the patient presenting with sepsis are summarised from the current literature. These steps include an oxygen administration, resuscitation with intravenous fluids and infusion of intravenous antibiotics. Also basic defiitions of sepsis with its subsequent stages are provided. Therefore, the reader will appreciate why a streamlined process in assessing patients in the emergency department is used, as well as have a thorough understanding of the importance of rapid and aggressive treatment of patients with sepsis.
- Penetrating eye injury
Penetrating eye injuries are serious ophthalmic emergencies that can result in severe loss of vision or loss of the eye. Patients who have sustained these injuries present to the emergency department and need prompt assessment and referral to an ophthalmic specialist. A foundation or junior doctor is often the first to diagnose and manage these patients. We present a case of a 28 year old patient who presented with a globe rupture and penetrating eye injury. We discuss the importance of a careful examination and highlight the steps taken in the initial management of these patients. We share the events that occur after referral to an ophthalmologist and the journey a patient goes through when faced with this traumatic injury.
- A traumatic C-Spine injury with extensive head wound
Patients with traumatic head injuries can be daunting to manage, especially in the middle of the night. It is imperative to approach the patient as per Advanced Trauma Life Support (ATLS) guidance and get senior assistance early. Closure of scalp wounds requires adequate time, appropriate analgesia, consent and knowledge of the difference techniques for wound closure and complications that can develop. I present a case of a 75 year old female who attended A&E in the middle of the night after a mechanical fall with an unstable, c-spine injury and a deep laceration to her scalp of unknown size or depth. I present the step – by – step process of this lady’s scalp wound closure with the issues raised, followed by MCQs.
- Patient suffered a traumatic C-spine injury with extensive head wound
Patients with traumatic head injuries can be daunting to manage, especially in the middle of the night. It is imperative to approach the patient as per Advanced Trauma Life Support (ATLS) guidance and get senior assistance early. Closure of scalp wounds requires adequate time, appropriate analgesia, consent and knowledge of the difference techniques for wound closure and complications that can develop. I present a case of a 75 year old female who attended A&E in the middle of the night after a mechanical fall with an unstable, c-spine injury and a deep laceration to her scalp of unknown size or depth. I present the step–by–step process of this lady's scalp wound closure with the issues raised, followed by MCQs.
- Imaging characteristics of common acute abdominal conditions
Acute abdominal pain accounts for 5-10% of visits to the emergency department, and imaging plays an important role in the management of these patients, especially as clinical evaluation results can be inaccurate. CT can provide accurate and reproducible diagnosis. Imaging has been shown to have a positive effect on the accuracy of the clinical diagnosis (1,2) to lead to changes in management decisions (3,4) and to increase the level of diagnostic certainty in patients with acute abdominal pains (5,6). It is with this in mind that we would like to illustrate the important imaging characteristics, on CT, of common acute abdominal conditions presenting to the Emergency Department.
- Management of the hot swollen joint H in adults in the Emergency Department
Though septic arthritis needs to be excluded when a patient is seen as an emergency, other causes of the hot red swollen joint such as gout, pyrophosphate and psoriatic arthritis, palindromic rheumatism and acute sarcoidosis, can be diagnosed with careful history, physical examination and simple investigations. The joint aspirate needs to be Gram stained, cultured and sent for polarised microscopy. Intra-articular corticosteroids should not be injected unless septic arthritis is confidently excluded. Swollen prosthetic joints are best referred urgently to the orthopaedic team.
- Haematuria
Haematuria is the presence of blood in the urine. Up to three red blood cells per high-power microscopic field is considered normal, but anything greater than this is significant and requires investigation.
- Guillian Barre Syndrome
You are a Foundation year 1 doctor on call in the Emergency Department. You see a 63 year old man, normally fit and well and returned from Sicily after a months holiday. He was fine until a week later, when he developed sudden onset explosive diarrhoea 5-6 times a day. This was associated with bilateral leg weakness leading to reduced mobility. Stool cultures were positive for Campylobactre jejuni. Over a week his diarrhoea continued, weakness progressed, was unable to walk and soon went into urinary retention, for which he was catheterised. He had no sensory symptoms. He now presented two weeks later, as being unable to move his hands and off legs completely since the previous afternoon. He had no further episodes of diarrhoea in the last 30 hours. His wife, who was with him on holiday remained well.
- Pyelonephritis
A 36 years old lady presents to the emergency department with left loin pain, nausea and vomiting. The pain has been increasing gradually over the past 24 hours with some fever and rigors. On further questioning it was revealed that she had two days history of urinary urgency, frequency and dysuria. Her initial observations showed pyrexia of 38.6c, tachycardia 106/min and hypotension BP 95/30. On examination her abdomen was soft but tender in the suprapubic region. She was also tender in the left loin with tenderness over the left costovertebral angle.
- Urinary retention
A 71–year–old gentleman presented to casualty with difficulty passing urine for over 12 hours and abdominal pain. How would you assess this patient?
- A case of D-Dimer negative pulmonary embolism
Pulmonary embolism (PE) presents a diagnostic challenge for the emergency physician. Undiagnosed PE is associated with a mortality of up to 30% although more recent data suggests a lower mortality rate (1). The advent of D-dimer testing looked to bring a sensitive “rule-out†test to EM. Reviews have shown the D-dimer testing is only accurate in the low-risk group (2). This article highlights a case of a patient who despite having clinical signs of a pulmonary embolism had their diagnosis delayed due to a negative D-dimer result. In conclusion it should be remembered that D-dimers are not sensitive enough to rule out PE in patients at high risk. Although the use of D-dimers initially promised to be very useful in ruling out PE subsequent reviews have suggested it is only accurate in low-risk patients.
- Rare manifestations of right iliac fossa pain
Diagnosis and management of right iliac fossa pain can be very challenging. It presents in approximately 50% of all acute abdomen cases, and although appendicitis raises the fist suspicion during initial assessment, the preoperative diagnosis is seldom accurate. Cross-referrals may occur between specialties and unexpected pathology may sometimes only be encountered as operative or histo-pathological finding. We present two rare entities of right iliac fossa pain, which signify the importance of clinical assessment and differential diagnoses in order to ensure correct diagnosis and management are achieved.
- An approach to a patient with symptomatic hyponatraemia
You are the Foundation Year doctor called to see Mrs A, a 69-year-old patient admitted with worsening confusion over the last week. You are unable to obtain a detailed history from the patient. The GPs letter explains that the patient has been treated for a presumed chest infection with oral antibiotics 2 weeks prior. She was advised by the GP to “drink plenty of water†to keep hydrated. Her AMT is 2/10. She is afebrile with a respiratory rate of 24, oxygen saturations of 93% on air. You begin to examine Mrs A when she suddenly develops a tonic-clonic seizure.
- The management of a patient with acute severe headache
A 50-year-old man presents to the A&E department with a severe headache. He says it came on abruptly about 5 hours ago while he was mowing the lawn and has persisted since. Paracetamol and ibuprofen have made little difference. He is normally healthy and has not experienced headaches of this intensity in the past. He has had one episode of vomiting since the headache started, but is otherwise feeling quite well. His neurological examination is normal, with no focal signs, and he is alert and orientated. He says that the headache came on very suddenly, was immediately very severe and was the worst headache he has ever experienced.
- A patient admitted following an overdose of paracetamol
A 19-year-old girl presented to the A&E department at 10.30am after having taken an overdose of 16g paracetamol at 8am that morning. There was no prior history of alcohol excess or recreational drug intake. She denied suicidal intent and was upset that she had taken the overdose, claiming that she would not attempt the overdose again. On examination she was tearful, but no abnormalities could be detected.
- The dissecting aorta
Aortic dissection is a rare vascular emergency with very high mortality if left untreated, thus needing rapid assessment and resuscitation with early involvement of high level care teams. Patients are usually acutely unwell at presentation, but a proportion of patients have vague and atypical symptoms and signs, making diagnosis diffiult and liable to error. Aortic dissection should be part of the differential diagnosis of any patient with chest, abdominal and back pain. It may also present in an atypical manner such as with syncope, abnormal neurological signs, congestive heart failure and respiratory or gastrointestinal bleeding. The structured diagnostic approach and immediate management for a patient presenting with chest pain is discussed.
- Management of severe sepsis and septic shock
Mrs B was an 82-year-old woman who was referred to hospital by her GP, after collapsing at home. She normally lived alone with twice daily visits from carers due to mild cognitive impairment. The care assistant who visited in the morning had noticed that Mrs B had been more confused than normal and had alerted her daughter; she had visited later to find Mrs B collapsed on the floor, incontinent of urine and confused. Mrs B had a past medical history of hypertension, for which she took amlodipine and ramipril, and diet controlled type 2 diabetes mellitus. She had no other significant co-morbidities and no allergies. A similar episode 1 year earlier had resulted in a hospital admission and had been attributed to a urinary tract infection. On that occasion she had responded to treatment with antibiotics and had been discharged from hospital after 1 week with her current care package.
- Management of ischaemic stroke on the acute medical unit (AMU)
Mr J, a 76-year-old male, is referred to the AMU with a 3-hour history of dense left-sided weakness, homonymous hemianopia, slurred speech and difficulty swallowing. His symptoms were present on waking earlier that morning. He has a past medical history of tablet-controlled type 2 diabetes and hypertension. He smokes 10 cigarettes per day (30 pack-year history) and drinks 40 units of alcohol per week.
- A patient admitted following an overdose: mental health and risk assessment
This article discusses the psychiatric assessment and management of a 46-year-old woman following an overdose. Risk assessment is essential following deliberate self harm, as is ensuring suitable follow-up. This case highlights the risks associated with repeated self-harm and what support can be offered to minimise such risks.
- The jaundiced patient with haematemesis
A 69-year-old man with known cirrhosis secondary to alcoholic liver disease presented to the A&E department. Prior to his presentation he reported having vomited several large cupfuls of bright red blood and then proceeded to have a further 500ml of fresh haematemesis while in the department. On examination he was pale, clammy, hypotensive and peripherally shut down, with a pulse of 105/min and blood pressure 90/40. He had peripheral stigmata of chronic liver disease including icteric sclera, multiple spider naevi and palmar erythema. Abdominal examination revealed hepatosplenomegaly and ascites. He was not clinically encephalopathic. Despite previously completing a community alcohol detoxification programme he had not been able to remain abstinent and had consumed approximately 50 units of alcohol in the preceding 3 days.
- Febrile seizure
A previously healthy 2 year old boy, born at term, presented to the Emergency Department with his concerned parents. They described an episode at home that morning which had lasted three minutes in total, where he went flppy and stiff and thrashed his arms and legs around. On arrival to the department he was no longer fitting; his temperature was found to be 39.2°C. He was examined and observed in the department where he was found to have a sore, red throat. He had no further seizures and was discharged home that afternoon with no follow-up.
- Diabetic hyperglycaemic crises
Introduction: type 2 diabetes mellitus is increasing in prevalence and patients may present in hyperglycaemic crisis. We present a case of mixed Diabetic Ketoacidosis (DKA) and Hyperglycaemic Hyperosmolar syndrome (HHS) in a previously unknown diabetic. Case Presentation: a 49-year-old man presented to the A&E department with polydipsia, polyuria, weight loss and confusion. Biochemical testing revealed evidence of both DKA and HHS. He was transferred to the intensive care unit for further management. Discussion: it is essential to distinguish between DKA and HHS because of differences in management, with outcome implications. HHS patients are at high risk of cerebral complications and mortality of up to 50% has been reported. Regimens aimed at treating patients with DKA, may exacerbate risk to patients with HHS who should be managed to minimise the risk of cerebral oedema.
- Clinical care of gall bladder disease
A 47-year-old Caucasian female secretary presents to her GP with a 2-week history of intermittent abdominal pain, each attack lasting up to 3 hours and gradually increasing in intensity. She is clinically obese and taking the combined oral contraceptive pill, having had three children. She has a 20-pack/day smoking history, and a reasonable diet, although it seems low in fibre. On admission to hospital her situation worsens. Her sclera are yellow, and she becomes pyrexial, with associated rigors. On examination she has pain in the right upper quadrant. ECG and chest X-ray show no obvious abnormalities.
- Abdominal compartment syndrome
A 30-year-old man with a BMI of 35, who had been admitted with acute pancreatitis 2 days previously, started complaining of increasing abdominal pain. On examination he was alert, oriented and apyrexial. He had a raised respiratory rate, tachycardia, low jugular venous pressure and blood pressure of 100/50. Chest examination was unremarkable. Abdominal examination demonstrated a markedly distended abdomen mildly tender in all four quadrants. Observation charts suggested at least a 4 litre positive fluid balance. Pulmonary embolus, sepsis and cardiac causes of shock seemed unlikely, so an initial diagnosis of hypovolaemic shock was made and investigations requested. Aggressive resuscitation was initiated with oxygen and intravenous fluids. On review 3 hours later, he was less alert. Respiratory rate had increased and a pulse oxymetry reading of 90% was recorded. The tachycardia had increased and blood pressure was unchanged. His abdomen had distended further and he had passed only 15 ml urine in the intervening period despite the prescribed fluids. Oxygen and fluid therapy were escalated, but the presumptive diagnosis of hypovolaemic shock seemed to be in doubt as the primary cause of decompensation as the patient was resistant to fluid resuscitation.
- Acute appendicitis
A 24-year-old girl presents with a 36-hour history of abdominal pain. This pain had become increasingly severe and was colicky in nature but with intermittent sharp episodes, and was felt mostly in the epigastrium. With time the pain became more generalised. She felt nauseous and vomited but had no haematemesis. She had lost her appetite over 2 days. Her bowels had not opened for 2 days, but prior to that she had had normal movements with no associated blood. She was passing only small amounts of urine, but had no dysuria or cloudy urine. She was 2 weeks past her last menstrual period and was taking the oral contraceptive pill but no other medications. She had had no previous abdominal operations.
- Management of the patient with transient loss of consciousness
An 84-year-old man was referred to hospital by his GP, after apparently collapsing in his residential home. Although fully alert and orientated on arrival in hospital, the patient was unable to describe in detail the circumstances which had resulted in his admission, except that he "had a funny turn". The GP's letter described his past medical history, which included hypertension and chronic obstructive airways disease, with a 40 pack-year smoking history. His only medication was ramipril 2.5mg daily and ipratropium bromide 4 times per day via inhaler/spacer device. Examination of Mr R revealed a quiet ejection systolic murmur in the aortic area and a bruise over his right eyebrow. His blood pressure is 140/70, with a pulse of 70/min.
- Airway management in odontogenic abscess
A 25 year old male presents to the ward with a 5 day history of a dental abscess and features of systemic toxicity (1, 2). The key features are the assessment of the compromised airway, the toxic patient and appropriate management for these conditions. Clinical review of the airway forms a vital part of planning for safe peri-operative care strategies for ward doctors and anaesthetists. Prompt assessment and anticipation of serious complications are paramount in patients with airway related compromise on the ward, in theatre and post-operatively.
- Critical incidents in anaesthesia
Critical incidents are unintended or unexpected incidents that may potentially cause patient harm. This article illustrates an example of a critical incident (CI) and discusses how to report a CI, what happens after a CI is reported, factors causing CIs, and methods to prevent or reduce harm from CIs.
- Tracheostomy & Laryngectomy Emergency Care
Dealing with airway emergencies in patients with tracheostomies and laryngectomies can be a daunting prospect for junior doctors. This case study demonstrates the importance of an understanding of tracheostomy and laryngectomy anatomy, different types of tracheostomy tube as well as potential causes of tracheostomy related emergencies. Employing a methodical, stepwise approach in these emergency situations allows simple, often lifesaving interventions to be carried out.
- Transfer medicine
The aim of this article is to focus on the transfer of critically ill patients. A critically ill patient is generally defined one who requires a level of care greater than that normally provided on any standard hospital ward i.e. ITU Level of Care (1-3). Patients on an intensive care or high dependency unit may be receiving intravenous infusions and/or being monitored by telemetry and highly qualified nurses. Despite this being the best environment for the care of these patients, for one reason or another, transferring critically ill patients from these units to other locations is quite common. These transfers are not without risks. During transport a patient’s clinical condition can deteriorate. The patient may suffer arrhythmia, desaturate, have difficulty ventilating, or suffer cardiac arrest. Furthermore equipment and monitoring may malfunction or suffer power loss. Therefore it is very important that a thorough assessment of the balance of risks and perceived benefits of any transfer is made at a consultant level before the decision to transport is made.
- Management of head injury
The assessment and management of head injury patients can be a daunting task for Foundation year doctors. This article emphasises the importance of accurate history taking and examination when assessing these patients and will discuss management of a difficult, yet common scenario.
- Post-operative complications
Worldwide it is estimated that approximately 200 to 250 million surgical procedures are performed each year. Many of these patients will suffer from one or more post-operative complications. Definitions of what constitutes a post-operative complication vary but the term generally suggests an adverse occurrence affecting a patient's well-being, which may at the very least delay recovery and in the worst cases result in lasting disability or death. Because of the difficulties in both defining post-operative complications and in gathering data, it is difficult to provide an accurate incidence of their occurrence but some studies have suggested figures as high as 30% or more. Post-operative complications may arise as a direct consequence of the surgical procedure or anaesthesia, or be related to underlying medical conditions and while not all will be serious or life-threatening even those which are mild and self-limiting may, nonetheless, be distressing to patients and since they may require treatment and prolong hospital stay, they may have significant cost implications.
- Paediatric anaesthesia & safeguarding children
These anatomical variations together with the physiological differences of increased metabolic rate and oxygen consumption mean that children will be more prone to rapid desaturation and hypoxaemia than seen in healthy adults.
- Postoperative recovery
Post-operative patients can be a vulnerable group and they should be monitored in an appropriate area and assessed by trained nursing staff and doctors. In order for these patients to receive optimal post-operative care we must take all the organ systems into account. Management includes optimisation of the respiratory and cardiovascular systems, fluid and electrolyte management, prevention and control of sepsis, and nutrition. You should only accept responsibility for management of a post-operative patient if you feel you have been adequately equipped with the skills necessary to do so. If not, never hesitate to call for assistance from someone who will be more experienced in dealing with these patients. This article will discuss the assessment of the postoperative patient, followed by discussion of the most common postoperative complications, their differential diagnosis, and their investigation and management.
- Intraoperative care
Intraoperative care lasts from the time the patient enters the induction room to when the operation is complete and the patient comes to the recovery ward. This article tries to familiarise the Foundation doctor with the operating theatre environment with an emphasis on measures which are in place to ensure the safety of patients. It observes the patient care in the intraoperative period from the anaesthetist's point of view.
- Preoperative assessment of the surgical patient
The term pre-operative assessment implies that surgery has been planned, and that the patient should be prepared for the operation. However, the definition of pre-operative assessment has evolved, especially as new technology has become available to aid medical assessment. As well as this, patients are now usually admitted to hospital on the day of surgery, and pre-operative assessment has therefore been significantly expanded in its scope. It now encompasses all interventions aiming at evaluating the health state of an individual patient, assessing risks, and recommending best perioperative management, as well as communicating this plan with the patient and the multi-disciplinary team. In this article we will discuss the value of pre-operative assessment and some of the key points of this work. We will also illustrate this with some examples from real patients.
- Regional anaesthesia for shoulder surgery
Shoulder surgery is a common orthopaedic procedure performed on both an inpatient and day-case basis. Excellent analgesia is essential for early mobilisation and improved postoperative function. Regional anaesthesia is used to provide good operating conditions and long lasting pain relief. Patients need to be clearly counselled how to look after the 'blocked' arm and to expect common side effects. Analgesia planning for when the block wears off is paramount. Dangerous complications are rare, but should be actively looked for in patients with atypical symptoms or slow recovery. In this article, we review the interscalene brachial plexus block and discuss the approach to some common postoperative problems.
- ARDS: When basic management fails, what happens next?
While working on the Intensive Care Unit (ICU), we came across a young trauma patient who developed ARDS secondary to fat emboli from a femoral fracture. He deteriorated rapidly despite maximal ventilatory support. An improvement was only demonstrated after proning the patient. In this article, we discuss the patient's management and reflect upon the new interventions that are being developed to manage ARDS; a condition that continues to carry a high mortality rate.
- Enhanced recovery after orthopaedic surgery
A 77 year-old man presents for elective major joint surgery. He has concerns that major surgery will not be feasible due to the disruption it will cause to his caring responsibilities for his wife, who suffers from severe dementia. His perioperative pathway is described and the principles of enhanced recovery after orthopaedic surgery are explained. These give him the best chance to return to optimal function as soon as practicable within current perioperative practice.
- Anaphylaxis: two cases and discussion
Anaphylaxis is an acute and potentially life threatening condition with systemic reactions. It is a medical emergency that foundation doctors are likely to deal with. Prompt recognition and management is critical. We describe two case reports of patients that developed anaphylaxis with different presentations and progression. The first case demonstrates a patient who developed anaphylaxis under general anaesthesia and the second describes a case of food-triggered anaphylaxis.
- Mechanism of action, monitoring & reversal of neuromuscular blocking agents: the use of Sugammadex
The classical triad of anaesthesia consists of hypnosis, analgesia and muscle relaxation. The introduction of neuromuscular blocking drugs (NMB) in the 1940's transformed the way in which anaesthesia could be safely delivered to patients. The NMB drugs provided the ability to paralyze patients to facilitate intubation of the trachea and provide muscle relaxation during major surgery. The NMB drugs work by occupying nicotinic Acetylcholine receptors (nAchR) in a competitive antagonism with endogenous acetylcholine (Ach) at the neuromuscular junction. At the end of surgery muscle paralysis usually needs to be reversed by the administration of anticholinesterase drugs such as Neostigmine. These drugs have known side effects which can give rise to problems in some patients. A new novel drug called Sugammadex has been introduced into anaesthetic clinical practice which has a completely different mechanism of action to reverse NMB drugs. It brings significant safety benefits for some patients. Its drawback is that it is expensive. In this article we will overview the role and mechanism of action of NMB drugs, including reversal, and will highlight some specific indications for Sugammadex.
- Competence, complications & consent in anaesthesia
Anaesthesia carries the potential to cause death or serious injury, risks which the patient should be made aware of. This paper explores contemporary standards of informed consent and the difficulties in achieving this within anaesthesia. The issue of competence in technical interventions as a specific component of consent is highlighted by a tale from civil litigation which demonstrates adverse consequences for both patient and practitioner.
- Chronic pain in the acute elective surgical setting
This summary covers the pathophysiology of pain alongside analgesic approaches to management of acute pain in patients with chronic pain as a case study. It will take you through a case from pre-operative assessment and the use of adjuvant therapy through to potential complications of acute pain management with questions to test yourself throughout.
- Suxamethonium apnoea during electroconvulsive therapy
This article describes a case of suxamethonium apnoea during ECT, highlighting this rare, but important adverse effect. It discusses how it is recognised, the immediate management and subsequent investigations, as well as discussing the risks of anaesthesia in remote areas.
- Recognition, assessment & management of the unwell patient On The Ward
Patients go to the hospital because they feel unwell. However, whilst in hospital, a patient who has been stable on the ward may acutely deteriorate and become critically unwell. Early recognition of the severity of the situation, careful assessment of the patient, prompt management using a systematic ABCDE approach, and effective communication between team members are the four main pillars to safely manage the unwell patient on the ward. The ultimate aims are the rapid stabilization of the unwell patient, the prevention of further deterioration, and the appropriate escalation of the patient's care. Most patients who become acutely unwell on the ward show signs of deterioration many hours before their acute decompensation. This may be due to the progression of the primary condition which brought them to a hospital, due to their pre-existing co-morbidities or due to a new problem they have developed since admission. The ability to recognise the early signs of deterioration and manage them accordingly is the key to improvement of the patient's outcome and survival. Physiological signs indicating a patient's deterioration include: reduced oxygen saturations, tachypnoea, hypotension, tachycardia, reduced level of consciousness and increased temperature. These parameters are documented by the nursing and allied healthcare professionals in the patient's observation chart and form a part of the NEWS (national early warning score) system.
- Post-operative delirium
We present the case of an 84 year old female who had a fractured neck of femur and developed acute confusion following administration of opioids. Her confusion resolved but it posed a challenge for the anaesthetic team. Delirium is well defined and common in occurrence and a good understanding is required at all levels, across all specialties. This paper will look into more detail at the risk factors, clinical assessment and treatment of delirium. We shall also look at the specific anaesthetic challenge posed by this patient.
- Insertion & care of central venous catheters
A central venous catheter (CVC) is a device that is inserted into the superior vena cava. Central venous catheterisation was first performed in 1929 and is now common practice in a variety of health care settings (1). Although CVCs may be inserted by any doctor who has been trained and competencyassessed, the majority are inserted by anaesthetists and intensivists to be used in the high dependency setting. Knowledge of the indications and care of CVC lines is, however, essential knowledge for any foundation doctor.
- A case of reduced GCS in an immunocomprimised patient
The ability to recognise the acutely ill patient is a skill that all foundation doctors should have and guidelines from NICE and surviving sepsis prompt this. Severe sepsis is a major cause of morbidity and mortality, with an annual mortality rate of 35% (1). The surviving sepsis guidelines implementation in hospital has been shown to reduce mortality, decrease length of stay and reduce intensive care bed days (2,3). The prompt assessment, institution of appropriate investigations and management and involvement of senior doctors has been shown to reduce mortality in this patient group. Sepsis Six is the name given to the bundle of medical therapies designed to reduce the mortality of patients with sepsis. These simple measure can save lives. All foundation doctors who will work in an acute receiving unit should possess these skills. Source control is fundamental to the treatment of sepsis and vital for overall morbidity and mortality. We present a rare case of reduced GCS in an immunocomprimised patient. Invasive fungal infections are rare, but should be considered in patients who are immunocomprimised, those with solid organ transplants taking immunosuppressants and those with haematological malignancies.
- Acute aortic dissection
Acute aortic dissection is the most common, life-threatening pathology affecting this vessel. It is caused by an intimal tear occurring in the wall of the aorta leading to a dissection plane within the media, separating the intima from the overlying adventitia. There is high risk of aortic rupture. Patients most at risk are those with connective tissue disorders and general cardiovascular risk factors, especially hypertension. Typically it presents with tearing chest pain, but can present atypically with collapse, myocardial ischaemia or neurological deficits. Patients can be misdiagnosed initially. We present two cases of aortic dissection highlighting differences in presentation and management between the different types of aortic dissection, and review current literature regarding optimal investigation and follow up.
- Diagnosis of broad complex tachycardias
In the vast majority of cases broad complex tachycardias [BCTs] are due to ventricular tachyarrhythmias, however they may also result from aberrantly conducted supraventricular tachycardias [SVTs]. Accurate diagnosis of BCTs is important and challenging. Differentiation should be based on clinical assessment, 12-lead ECG and the response to drugs. Haemodynamic compromise is not a reliable distinguishing feature. SVTs respond to AV nodal [AVN] blockade whereas VT does not. Furthermore, verapamil may precipitate haemodynamic collapse or death in patients with VT and should be avoided. Where the diagnosis is unclear or when faced with haemodynamic instability the patient should be treated as having VT. The aim of this article is to provide a step-by-step approach for diagnosing BCTs.
- Endocarditis & mitral valve prolapse
A 63 year-old man with a known diagnosis of mitral regurgitation had been referred for outpatient mitral valve repair. Whilst on the waiting list for surgery, he presented with weight loss and night sweats. Echocardiography showed severe mitral regurgitation secondary to mitral valve prolapse and a large vegetation adherent to his mitral valve. Blood cultures subsequently grew a Strep Mitis organism and he was started on IV antibiotics. This man did not have features of congestive cardiac failure, and traditional management may have taken a conservative approach; e.g. prolonged course (days to weeks) of IV antibiotic administration prior to surgical intervention. However, in view of recent evidence showing a reduction in mortality when early cardiac valve surgery is performed in patients with large endocarditic vegetations (1), urgent surgery was arranged and he underwent mitral valve replacement with a good result. This case highlights the diagnostic challenges of endocarditis, and reflects on emerging evidence supporting early surgical intervention for endocarditic patients with large (>10mm) vegetations (1).
- Mitral regurgitation & mitraclips
The patient in our case has a complex cardiac history and presents with the common problem of breathlessness. The various cardiac causes for this are explored, identifying salient features that should be sought in the history of any patient presenting with the same problem. Features of his examination and a list of investigations identify his primary problem as mitral regurgitation (MR), with evidence behind some of the tests provided. Acute general management of MR expected from the Foundation doctor and longer term specialist management options are then explored, including the use of a MitraClip.
- Syncope
Syncope is defined as a transient loss of consciousness and is a specific term that excludes seizures, coma, shock or other altered states of consciousness. It is extremely common and frequently presents to the emergency department. Evaluation of the event through a detailed medical history will form the basis of the diagnostic strategy and will enable the stratification of patients according to risk. This article provides a simple approach on how to assess, investigate and evaluate patient risk. Furthermore we categorise syncope into its different causes providing a diagnostic framework and management plan for each. Some syncopal episodes may be easily diagnosed on history alone whereas others may require a careful diagnostic workup involving specialist input. The management of syncope is entirely dependant on the cause and can vary from supportive measures to invasive procedures. This highlights the importance of the initial history and subsequent diagnostic investigations. This article will provide junior doctors with the confidence to manage syncope in the busy emergency department allowing them to make important decisions on whether to admit or discharge.
- Chest pain: an approach for F1 doctors
Mr KL, a 48-year-old Irish businessman, arrives in hospital with a two hour history of severe retrosternal chest pain radiating to both sides of his chest, and into his neck and back. It came on suddenly, at rest, and although it seemed to be improving for a while, has got much worse in the last hour.
- Cardiovascular risk factors
You are asked to see a 43-years-old male patient who is due to be discharged following a successful hernia operation. He is very concerned about his health as his father died of a heart attack aged 51 years, however he continues to smoke 20 cigarettes a day. Blood pressure has been measured as 165/89, but the remainder of the clinical examination is normal. An ECG shows sinus rhythm at 80 bpm, with no abnormalities seen. Fasting blood tests reveal a total cholesterol of 6.3, with an LDL level of 3.9 and an HDL level of 0.8, and the patient’s fasting blood sugar is also slightly elevated at 6.5. He asks you what his chances of having a heart attack are and what can be done to minimise the risk – what do you tell him?
- Infective endocarditis
A 43-year-old man presents with fever and myalgia for seven days. He also complains of chronic chest pain for six years without an obvious cause.
- Arterial fibrillation: arrhythmia
You are called to the ward to see a 76-years-old lady who had a hemicolectomy four days ago. They have noted that her pulse is 156 whilst taking her observations. She feels a little bit short of breath, but otherwise reports no symptoms. What do you do next?
- Not all chest pain is cardiac, even when the troponin is high
A 64 year old man presents with central chest heaviness, dyspnoea with a positive troponin and is diagnosed with a myocardial infarction. This scenario is encountered frequently on the acute medical take but differentiating acute coronary syndromes from other causes of chest pain is not always straight forward. This article provides an overview of the case and investigations and reviews the reasons for troponin elevation and the pitfalls of assuming that this always represents myocardial infarction.
- An approach to the unwell patient post-PCI
As percutaneous coronary intervention (PCI) becomes more prevalent, it is increasingly likely that Foundation doctors will be required to review those patients who have undergone this procedure when they become unwell, and carry out appropriate initial investigation and management. We present a fictional case of hypotension in a patient who has recently undergone PCI. This is a not uncommon scenario, and one for which there is a broad differential. We discuss these key differential diagnoses, and show how a structured approach to history and examination can allow them to be narrowed down to a final diagnosis, allowing prompt and appropriate management.
- Thyrotoxicosis induced heart failure with secundum ASD
Thyrotoxicosis is a rare but reversible cause of pulmonary hypertension and right heart failure. Treatment of the thyroid disorder usually leads to complete normalisation of the pulmonary artery pressure and right ventricular function. This patient had a co-existing secundum atrial septal defect (ASD) which made her management challenging. This case illustrates the interplay of various factors leading to her presentation and subsequent management and the multi-disciplinary team (MDT) approach in her treatment.
- Palpitations or panic attack?
A 72-year-old lady was seen by her general practitioner and attended her local emergency department on several occasions over a 9-month period with episodic symptoms. She had attended the emergency department three times in the preceding 5 days. Her symptoms consisted of palpitations, light headedness, chest tightness and shortness of breath. The palpitations were of rapid onset and offset and consisted of a sensation of a rapid regular heart beat. She had been previously diagnosed as having an anxiety disorder, and the episodes attributed to panic attacks (1). She was otherwise in general health.
- The acute management of supraventricular tachycardia
A 24 year old male is referred to the medical receiving unit with a 4 hour history of sudden onset of palpitation which he describes as a feeling of his heart racing. He denies any chest pain, breathlessness or light-headedness. These symptoms came on while he was sitting watching TV. He had consumed 4 pints of beer.
- Acute thoracic aortic syndromes
A 25-year-old man presents to the emergency department with chest pain. The patient describes severe, sudden-onset, central chest pain radiating through to his back, which came on whilst out walking his dog. The patient claims to have been previously fit and well with no significant past medical or surgical history. He is a non-smoker, drinks alcohol very occasionally and denies taking any regular medication. In the emergency department, the patient appears pale, sweaty, tachypnoeic and in obvious pain.
- An ACS but not as we know it?
The on call medical F1 was called to A&E to review a 56 year old Caucasian female presenting with chest pain. The history was of acute onset severe, central crushing chest pain, with no radiation or associated features. The pain was at its most intense for two hours, starting while at the funeral of her husband. The trigger was felt to be a poem being read by her son, which triggered an intense emotional response. The pain continued intermittently for the subsequent 24 hours but was ignored and put down to the stress of the day. She presented to her A&E the following afternoon, encouraged by other family members.
- Interpreting atrioventricular block
A 23 year-old man presents with palpitations and presyncope with evidence of non-conducted P waves at low heart rates, and frequent narrow-complex tachycardia. A dual chamber pacemaker was implanted for presumed sinus node dysfunction, second-degree atrioventricular (AV) block and atrial flutter. Many years and two pacemaker generator changes later he underwent an electrophysiology study that revealed normal AV node and His-Purkinje function, a concealed accessory pathway, and orthodromic atrioventricular reentrant tachycardia. We scrutinize his case, discuss AV conduction anomalies, and consider an alternative investigation strategy
- Cardiac masses
Cardiac Masses can often be found incidentally on routine testing and may present with a variety of non specific symptoms. Diagnosis is predominantly made via transthoracic echo (TTE) or transoesophageal echo (TOE), where the cardiac chambers can be visualised clearly. In this article, we present two cases where cardiac masses were found and treated in different ways and posed certain diagnostic challenges to the clinician. In the first case, an incidental myxoma proved to cause serious complications for the patient’s quality of life and livelihood. The second case is still currently being investigated as a cause is yet to be found for the symptoms this patient presented with a week after diagnosis of alcoholic cardiomyopathy.
- Heart failure
This case based discussion focuses on the treatment of advanced heart failure and highlights the required skills of careful clinical assessment, interpretation of tests and drug manipulation to optimise cardiac function.
- Myocardial infarction due to thrombosis of coronary artery aneurysm
A 65-year-old male self-presented to the Accident and Emergency (A&E) department with severe sudden onset central chest pain. He was diagnosed with non-ST-elevation myocardial infarction (nSTEMI) which had occurred due to poor compliance with prescribed anticoagulation leading to thrombosis of a longstanding coronary artery aneurysm, rather than a coronary stenosis. This required some deviation from ‘standard’ nSTEMI management. Clinicians should tailor evidence-based guidelines to the individual circumstances of each patient, rather than adopting a ‘one size fits all’ attitude, and good communication between professionals and patients is key to optimal medical care.
- Systolic hypertension
Systemic hypertension is very common amongst adults, and is a major risk factor for cardiovascular events. Isolated systolic hypertension is the most common variant in the elderly, making up sixty percent of the cases in this age group. This case demonstrates the assessment of a patient presenting with newly diagnosed isolated systolic hypertension; including a full history, examination, routine investigations and grading of cardiovascular risk. Management is based on a combination of lifestyle measures, in this case followed by drug treatment. For introduction of medication a step-wise algorithm is used, aiming to combine drugs in the most logical way to maximise the fall in blood pressure. Systemic hypertension requires lifelong follow up and the majority of patients will need combinations of medications to adequately treat the condition.
- Cardiomyopathy
This case based discussion explores the acute assessment of a 64-year-old man presenting with heart failure, followed by subsequent investigation and long-term management strategies for his underlying cardiomyopathy.
- Hyperlipidaemia
This case based discussion focuses on a lady with hypercholesterolaemia following an acute admission for severe sepsis. We will discuss the assessment, differential diagnosis and management of secondary hyperlipidaemia.
- Cardioversion
A 69-year-old practicing dentist was referred by his GP with a 6-month history of mild exertional dyspnoea and a newly detected systolic murmur. He was still able to play 18 holes of golf using a motorised trolley and had no symptoms at rest.
- Supervising an exercise treadmill test
The exercise treadmill test, usually performed to a graduated routine known as the Bruce protocol, has been a standard test for investigating chest pain and ischaemic heart disease (IHD) for many years and is still very widely used. As a Foundation Year colleague you may be asked as part of your programme in cardiology or acute medicine to assist with the supervision of these tests. When used properly they are easy to do, informative and a very useful contribution to the diagnosis and subsequent treatment of patients with ischaemic heart disease. In this short paper, we have tried to summarise the indications for treadmill testing, the pretest contraindications to look out for, the test itself, what constitutes a positive or negative test and the possible complications. It is by necessity a brief run-through and further reading is recommended below. The section about the test itself has been written by a senior cardiac physiologist and a consultant nurse. When supervising a test, you should always be accompanied by a well-qualified cardiac physiologist or nurse and do not feel any qualms about asking them for help and advice. Many of them have supervised literally thousands of tests.
- Secondary prevention after MI
A 40-year-old lorry driver presented to the Emergency Department an hour after onset of central chest pain. He was a smoker with a family history of coronary artery disease. His 12 lead electrocardiogram confirmed an acute anterolateral ST elevation myocardial infarction (STEMI). Following intravenous morphine for analgesia and anti-emetics, he underwent immediate primary percutaneous coronary intervention (PCI) with preoperative loading doses of aspirin and clopidogrel, as well as an intravenous bolus dose of heparin.
- The patient with syncope
A 55-year-old black male experienced an episode of loss of consciousness while attending a funeral in Trinidad. He had flown from the UK the day before and although a little "jet-lagged" was feeling his normal self. Shortly after the ceremony he found himself in a collapsed state in the toilets of the hotel at which he was staying. He had no recollection of the events surrounding his circumstances and was not aware of any warning or aura. He assumed he had possibly had too much to drink or had simply fainted. He attended a local hospital, to check that nothing more serious was responsible. There was no shortness of breath, ankle swelling or chest discomfort.
- Non-specific symptoms in a patient with valvular heart disease
A 46-year-old man presented to our medical assessment unit with a 3-week history of general malaise, muscle aches, night sweats, decreased appetite and a sore throat. He had been lost to follow-up at his local cardiology department with a diagnosis of aortic regurgitation (severity unknown). He had no other past medical history and was on no regular medication. Of note, his son had been diagnosed with a bicuspid aortic valve.
- Management of non-ST elevation acute coronary syndrome
A 62-year-old manual worker presents to the A&E department with a 2-hour history of central chest pain radiating to both arms. His pain subsided after being given sublingual glyceryl trinitrate and aspirin 300mg in the ambulance. Prior to his admission he smoked 20 cigarettes a day for over 40 years. Examination was unremarkable.
- Management of hypertension in primary care
Mr Smith is a 59-year-old Caucasian gentleman, who presents to your GP clinic for the third time with a persistently raised blood pressure of 170/100. Mr Smith reports no significant past medical history and denies any medication.
- Raised alkaline phosphatase
This case based discussion focuses on the causes and investigation of a raised alkaline phosphatase.
- Sodium imbalances for the Foundation doctor
One of the most common and sometimes complicated electrolyte abnormalities encountered in hospital patients are sodium imbalances. Unlike the management of other electrolyte imbalances, which are guided by specific well-established guidelines, sodium disorders are often not managed as well. This is because of the larger array of causes and aspects of management that can be employed. It is hoped that this article will go some way to aiding Foundation doctors in their understanding of abnormalities of serum sodium levels and how to approach their investigation and management.
- Diagnosis and management of hypercalcaemia
A 55-year-old teacher presents to the medical admissions unit with a 3-week history of polydipsia, polyuria and constipation. Further history reveals she had been fatigued, with poor concentration and myalgia for at least 6 weeks. She was previously well having never smoked, and drinking between 4-7 units of alcohol per week. She had her last menstrual period at the age of 51 and is on bendrofl umethiazide 2.5 mg once daily for mild hypertension. Examination is unremarkable, though she mentions a generalised aching pain in her proximal muscles, which are mildly weak (4/5 power).
- Skin cancer
A 76-year-old caucasion man was referred by his general practitioner to the dermatology outpatients clinic because of a non-healing skin lesion on his scalp.
- Skin biopsy
A 35-year-old man on the ward has developed palpable purpura to his lower legs which are clinically thought to represent a cutaneous small vessel vasculitis. You are asked to take a skin biopsy to help confirm the diagnosis.
- Pyoderma gangrenosum
A 60-year-old lady is referred to the dermatology department with an enlarging ulcer on her lower leg over the last month. She complains of generalised lethargy. She has no past medical history of note.
- Prescribing in eczema
A 10-month-old girl was referred to our department with an itchy, erythematous eruption. It started at 8 weeks of age and episodes of exacerbation and remission were observed. Her parents reported that her skin had been worse over the winter. There was a family history of asthma. On examination she had a symmetrical, erythematous, scaly, weepy eruption affecting her cheeks, neck, ankles, knee and elbow flexures.
- Bullous disorder
A 70-year-old man admitted with pneumonia was found on examination to have a number of blisters on his legs and evidence of excoriation elsewhere. He had been living at home with his dog. He had not been to consult his GP despite having had trouble with his skin for a few months. His past medical history is otherwise unremarkable. What would be your differential diagnosis for his rash?
- Manifesting carrier for Becker Muscle dystrophy
This is a case summary based on an adolescent presenting at the age of 10 years with an inherited neuromuscular disease manifesting as scoliosis. The report highlights her clinical history, examination, investigations, complications and multidisciplinary management. It emphasises a holistic family-centred approach to care of chronic paediatric disabilities.
- The pigmented skin lesion: the role of biopsy in dermatology
Diagnostic skin biopsies play an essential role in dermatology and provide information that can be correlated with the clinical impression to give a diagnosis. We discuss the presentation and management of two patients with pigmented skin lesions in order to highlight some important principles of skin biopsy. The biopsy strategies varied in each case due to the clinical impression, the size and site of the lesion. Excisional biopsy is the method of choice for clinically suspicious lesions. Other methods such as incisional biopsy, punch biopsy or curettage may be used for benign or pre-malignant lesions depending on lesion characteristics and patient preference.
- Generalised skin rash
A generalised skin rash progressing to full thickness skin necrosis is described in a 71-year-old male presenting with upper gastrointestinal bleeding in the presence of alcoholic liver disease. The clinical diagnosis, role of investigations and management are discussed. An infective aetiology is postulated for the rash.
- Neonatal resuscitation and intensive care
Neonatal resuscitation and intensive care is based on a systematic approach. In this article, an atypical case of neonatal respiratory distress highlights fundamental transferable lessons applicable to all foundation trainees. Although neonatology is a complex speciality, knowledge of the key differences between adults and neonates will help to reinforce resuscitation principals and the important points of clinical assessment. An increased focus on respiratory distress and causes of neonatal sepsis, will allow juniors to manage many problems effectively. Finally, in paediatrics it is of increased importance to consider and involve the family.
- Undescended testes
Undescended testis is a common indication for referral to paediatric surgery. Its surgical management is guided by clinical examination findings. We present a case based discussion encompassing the aetiology, presentation, surgical management and outcome of an undescended testis.
- Hemolytic uremic syndrome (HUS) in children
This case-based discussion is based on an 8-year-old girl who presented with haemolytic uraemic syndrome (HUS) characterised by the triad of thrombocytopenia, micro-angiopathic hemolytic anaemia and acute renal failure, following a diarrhoeal illness caused by escherichia coli O157:H7. The case will highlight relevant aspects of clinical history, physical examination, laboratory investigations, pathophysiology, complications, prognosis, disease notification, management and follow-up of children presenting with HUS. The most common cause of HUS is systemic uptake of toxins in 5–10% of individuals infected by Shiga-like toxin-producing E. coli (STEC). Other infective agents such as pneumococci and HIV, complement genetic abnormalities, medications, transplantation, malignancy or autoimmune diseases are responsible for 10% of cases of HUS, referred to as atypical or D-HUS.
- A youngster with a swollen eye
This 6-year-old boy presented 24 hours earlier to A&E department complaining of a swelling of the right eye. He was assessed by a Casualty officer and given oral antibiotics for presumed peri-orbital cellulitis. His parents returned to A&E the following day as the swelling had progressed and he was unable to open his right eye. On examination there was no evidence of discharge or trauma. The boy's mum indicated that he had only a minimally ''runny'' nose. He had a mild pyrexia.
- A challenging case of deliberate self harm/self injury in the young adolescent
This article gives a brief history of a deliberate self harm/self injury case in 2 young girls followed by a discussion about the management of the patients. Within the discussion a number of important factors will be briefly discussed including Gillick competence, capacity, confidentiality, child protection and the Acts that encompass all these issues (i.e. Mental Health Act, Mental Capacity Act and the Children Act). The reader is advised to refer to Trust and Local or National policies for further information.
- Childhood limp: a delayed presentation
A case of delayed presentation of an important cause of painless limp in a 14-month-old child is described. The differential diagnosis is mentioned, and risk factors for the condition are discussed.
- An unusual rash in a young woman - differential diagnosis and management of a vasculitic rash with systemic features
We present the case of a young lady aged 28 who developed an extensive skin rash over her lower limbs following a viral infection. The features were those of a palpable purpura and were associated with abdominal pain, diarrhoea which became bloody, arthralgia and asymptomatic haematuria. She had a low grade fever and elevated acute inflammatory markers. A clinical diagnosis of Henoch-Schönlein purpura was made and prednisone commenced at the dose of 20mg daily. A rapid symptomatic improvement followed, with resolution of the abdominal pain and diarrhoea, followed by a more gradual reduction in the rash over several weeks.
- Diabetic hyperglycaemic crises
Introduction: type 2 diabetes mellitus is increasing in prevalence and patients may present in hyperglycaemic crisis. We present a case of mixed Diabetic Ketoacidosis (DKA) and Hyperglycaemic Hyperosmolar syndrome (HHS) in a previously unknown diabetic. Case Presentation: a 49-year-old man presented to the A&E department with polydipsia, polyuria, weight loss and confusion. Biochemical testing revealed evidence of both DKA and HHS. He was transferred to the intensive care unit for further management. Discussion: it is essential to distinguish between DKA and HHS because of differences in management, with outcome implications. HHS patients are at high risk of cerebral complications and mortality of up to 50% has been reported. Regimens aimed at treating patients with DKA, may exacerbate risk to patients with HHS who should be managed to minimise the risk of cerebral oedema.
- A case of acidosis
A 59-year-old male presented to the resuscitation room of the emergency department with a gradual onset of shortness of breath over the preceding 2 days. There was no associated chest pain, cough, haemoptysis, fever or other symptoms. A past medical history of type 2 diabetes mellitus, hypertension and hypercholesterolemia were noted. At the time of attendance, he was on metformin, gliclazide, an ACE inhibitor and a statin.
- Addison's disease: An endocrine emergency
Primary hypoadrenalism, also known as ‘Addison’s disease’ is a rare condition, currently affecting around 8,400 individuals in the United Kingdom (1). Often insidious, it is potentially life-threatening if not recognised and treated promptly. This article aims to highlight the diagnosis, investigation and management of Addison’s disease by focussing on a patient who presented acutely to our Emergency Department.
- Dealing with diabetes foot problems in the acute setting: assessment & management
Diabetic foot disease is common and is often poorly managed leading to adverse complications. Every diabetes patient admitted to hospital should have both feet inspected and carefully examined. Any features of inflammation, ulceration or deformity should lead to a prompt referral to a member of the multidisciplinary diabetes foot care team. This will help ensure patients receive the best possible treatment early, leading to a shorter length of stay and a reduction in possible amputation.
- The management of diabetic ketoacidosis
Diabetic Ketoacidosis (DKA) is a potentially life threatening condition characterised by hyperglycaemia, ketonaemia and metabolic acidosis, as a result of relative or absolute insulin deficiency. As the prevalence of diabetes continues to rise, it is important to be able to understand why each treatment is given and to be able to manage patients who present with this condition effectively. In this article, we discuss the pathophysiological aspects of DKA, followed by an overview of aspects of management from presentation leading to recovery.
- Adrenal physiology & primary adrenal insufficiency
The adrenal gland is composed of adrenal cortex (which is divided into 3 zones in the adult gland) and the adrenal medulla. The cortex produces aldosterone, sex hormones and cortisol, which are all synthesized from cholesterol. Adrenal medulla produces the catecholamines. Cortisol is an endogenous steroid, which is essential for life. Aldosterone promotes sodium retention and potassium elimination by the kidney. Catecholamines stimulate the “fight or fight†reaction. Adrenal insufficiency is a life-threatening disorder, which is characterized by deficient production or action of glucocorticoids and/or mineralocorticoids and adrenal androgens. Adrenal insufficiency may result from disorders affecting the adrenal cortex (primary), or the anterior lobe of pituitary gland/hypothalamus (secondary).The clinical diagnosis of adrenal insufficiency can be confirmed by demonstrating inappropriately low cortisol secretion. Treatment of adrenal insufficiency should be initiated as soon as the diagnosis is confirmed, or even sooner if the patient presents in an adrenal crisis. Education to the patient and caregivers is essential part of the management. Acute adrenal crisis is an emergency, which requires prompt intervention, can manifest as a hypovolemic shock. Management is by supportive measures and intravenous glucocorticoid replacement.
- Hyponatreamia: An approach to investigation & managment
Hyponatraemia is the most common electrolyte abnormality in clinical practice (1). It is defined as serum sodium of less than 135mmol/L (2). Its presentation varies between patients and will often relate to both the severity of hyponatraemia as well as the rate of fall (3). The causes of hyponatraemia are numerous, and a systematic diagnostic workup is necessary in most cases. This article will review the case of a 65 year old lady who presented with complications of severe hyponatraemia, and discuss a structured method of investigating and managing similar patients in the hospital setting.
- Hyperthyroidism: failure of medical treatment
A 42 year old male presented with weight loss, fine resting tremor, proximal muscle weakness, abdominal pain and vomiting. He was found to have primary hyperthyroidism and primary hypercalcaemia. Treatment with carbimazole, propylthiouracil, Lugol’s iodine and prednisolone were unsuccessful in achieving euthyroidism. Thionamide treatment precipitated deranged liver function tests. The patient refused radioiodine ablation and underwent a successful total thyroidectomy whilst hyperthyroid. This case highlights the challenge posed by failure of medical treatment in hyperthyroidism, as further management options require patient euthyroidism. We demonstrate that a total thyroidectomy can be performed in a hyperthyroid patient if necessary.
- Newly diagnosed type 2 diabetes
We focus on a 53 year-old man admitted to hospital with an acute coronary syndrome whose random capillary blood glucose is found to be 18 mmol/L. We discuss the diagnostic tests required to diagnose diabetes, and describe the acute management of hyperglycaemia and well as subsequent in hospital and community based management required for such patients with a new diagnosis of type 2 diabetes.
- Hypoglycaemia
Diabetes mellitus is highly prevalent in hospitalised patients affecting around 15% of inpatients in England and Wales (1). Hypoglycaemia is a feared complication of diabetes and affected around a fifth of inpatients with diabetes surveyed during the recent National Inpatient Diabetes Audit (1). Hypoglycaemia episodes are likely to be encountered and managed by doctors in training, particularly during out-of-hours care when specialist support may be limited. Foundation doctors need to be aware of the management of hypoglycaemia in the acute setting and how to prevent further episodes. This case outlines the presentation and emergency management of hypoglycaemia in a patient with type 1 diabetes and discusses the salient points which should be included in their initial assessment and management.
- The short synacthen test
A 32-year-old man presented to the Accident and Emergency department with a 3-day history of persistent vomiting. He had felt increasingly tired with weight loss over the previous few months despite returning recently from holiday in Spain. He reported that his clothes were looser than usual and his suntan had persisted, but did not complain of additional symptoms. In particular, his bowel habit was normal and he had not experienced abdominal pain. His previous medical history was unremarkable and the patient was taking no medications. There was a family history of hypothyroidism affecting his mother and sister.
- Diabetic ketoacidosis: diagnosis and management in adults
A 25-year-old man presents to the Emergency department with a 2-week history of polyuria and polydipsia and a 2-day history of vomiting and abdominal pain. In the past fortnight he has also noticed some weight loss and progressive generalised weakness. He has been fit and healthy and is not on any regular medication.
- Management of a thyroid nodule
A 56-year-old non-smoker presented with a 2-year history of a swelling in the front of the lower part of her neck. The swelling was of an insidious onset with no significant increase in size and there was no associated discomfort reported. However, occasional pressure symptoms were noted as well as a “feeling of something†in her throat. There had been no weight loss recorded. On examination, she was found to have a 4×3 cm swelling which seemed to be localised to the isthmus and adjacent part of the left thyroid lobe. This classically moved upwards upon swallowing. There was no associated lymphadenopathy. Initial clinical evaluation suggested the swelling to be a thyroid nodule.
- Clinical care of gall bladder disease
A 47-year-old Caucasian female secretary presents to her GP with a 2-week history of intermittent abdominal pain, each attack lasting up to 3 hours and gradually increasing in intensity. She is clinically obese and taking the combined oral contraceptive pill, having had three children. She has a 20-pack/day smoking history, and a reasonable diet, although it seems low in fibre. On admission to hospital her situation worsens. Her sclera are yellow, and she becomes pyrexial, with associated rigors. On examination she has pain in the right upper quadrant. ECG and chest X-ray show no obvious abnormalities.
- Hyperglycaemic hyperosmolar state
Hyperglycaemic hyperosmolar state (HHS) is a complication of diabetes mellitus seen in the acute medical setting. It is a challenging condition to diagnose and manage, and there are currently no comprehensive guidelines. This article aims to give an overview of HHS in order to help Foundation doctors identify and treat these patients.
- Familial hypercholesterolaemia
This case focuses on an asymptomatic 36 year-old man referred to a specialist lipid clinic by his GP for a raised cholesterol on routine blood test, and discusses the assessment and management of a patient with possible familial hypercholesterolaemia (FH).
- Amiodarone and the thyroid
Amiodarone is a highly effective and frequently used treatment for cardiac arrhythmias. This article reviews the effects of amiodarone on the thyroid, and discusses the diagnosis and treatment of amiodarone-induced thyroid dysfunction.
- Management of newly diagnosed type 1 diabetes
Type 1 diabetes is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin. Diagnosis is confirmed when a patient presents with hyperglycaemia, polyuria, polydipsia and weight loss and a random laboratory blood glucose concentration of more than 11mmol/L; as is a fasting blood glucose concentration that exceeds 7mmol/L. Management of a newly diagnosed type 1 diabetic patient depends on the severity of the presentation, but all patients need immediate insulin treatment. If a patient presents with diabetic ketoacidosis (DKA), this must first be managed appropriately in a hospital setting and includes commencing the patient on an insulin regime. In a stable diabetic patient the most common regimen includes twice daily insulin or multiple daily injections and some patients might benefit from continuous subcutaneous infusion. Once a patient is established on insulin it is important to educate them on glycaemic control, how to manage hypoglycaemic episodes, complications of diabetes, diet and exercise, and what to do in pregnancy planning. Yearly screening is required to look for any signs of long-term complications of diabetes. The current HbA1c reference method changed in June 2011, to a new reference method, to create a standardised reference method for measuring HbA1c.
- Investigation of the thyroid nodule
Thyroid nodules are a common finding. These present as palpable nodules, or as an incidental finding through imaging for other reasons. Of all thyroid nodules found, as few as 5% represent a thyroid cancer. Traditionally the evaluation of a thyroid nodule commences with a thorough history and focused examination. This is followed by routine measurement of the thyroid hormones (T3 & T4) and Thyroid stimulating hormone (TSH). This immediately determines whether the nodule is causing a hormonal disturbance, which can give clues to its cancerous potential. Nodules resulting in hyperthyroidism should undergo radionuclide scanning which can support the diagnosis of a benign thyroid nodule if shown to be "hot". Ultrasound can confirm the presence of a nodule and in experienced hands identify features suggestive of malignancy. Ultrasonography is unable to definitively refute the presence of thyroid malignancy, rendering fine needle aspiration (FNA) biopsy the most accurate method for evaluating a nodule. A FNA biopsy is however an invasive method for evaluating nodules and following this procedure, the cytology results are not always clear-cut. Cytology results including "non-diagnostic" and "suspicious" often present clinicians with challenging dilemmas with regard to further investigation. Options include a further FNA biopsy, with studies supporting the use of ultrasound guidance in accurately identifying suspicious areas of the gland. Ultimately removal of the gland through surgery will determine its histology and eliminate any risk of malignancy posed by the gland.
- Carcinoid tumours
Carcinoid tumours are slow-growing neuroendocrine neoplasms that often are indolent and may not become clinically apparent unless develops metastases or carcinoid syndrome. As they originate from neuroendocrine cells, they have secretory properties and may frequently present with hypersecretory syndromes. Carcinoid syndrome usually manifests once liver metastases are present, secreting hormones directly into the systemic circulation. Overall incidence is estimated to be 2–3 cases per 100,000 people annually, but recent evidence suggests the incidence is steadily increasing. Although the disease was thought to be relatively benign, it is now considered to be one of increasing malignancy. They can present in a myriad of ways and at times present a diagnostic challenge. The choice of treatments depends on the symptoms, stage of the disease, degree of uptake of radionuclide and histological features of the tumour.
- The management of dyslipidaemia in type 2 diabetes
Total cholesterol and low-density lipoprotein (LDL) cholesterol exhibit an independent and strong correlation with cardiovascular events. The National Service Framework (NSF) for Diabetes, and the NICE Guideline on the Management of Blood Pressure and Blood Lipids discuss the evidence of tight lipid management in patients with diabetes and both recommend regular review of patients with type 2 diabetes, incorporating routine assessment of cardiovascular risk, from the time of diagnosis. The NSF further requires PCTs to ensure that regular review underpins a systematic treatment regimen for people with diabetes. NICE suggests that the vast majority of patients with type 2 diabetes are at high risk of CV disease and recommended the UKPDS risk engine for specific numerical estimation of risk. Cardiovascular risk in type 2 diabetic patients should be assessed according to NICE gui dance set out in 2008 and specific numerical cardiovascular risk should currently be assessed using the UKPDS risk calculator. Correction of dyslipidaemia produces a 5-year reduction of major coronary events, coronary revascularisation, and stroke are reduced by approximately one fifth per mmol/L reduction in LDL cholesterol. The primary thrust of treatment for dyslipidaemia is correcting lifestyle factors. Medical therapy should be initiated with low dose simvastatin once daily. Lipid levels should be re-assessed after 1-3 months of altering treatment and if satisfactory should be repeated yearly thereafter. Further treatment options if lipid control is not achieved include a graduated increase in simvastatin dose, switching to atorvastatin in the first instance if trial of a different statin is considered, or finally considering new emergent therapies in specific circumstances. At the present time opinion is that the benefits of statins currently far outweigh their risks.
- Diabetes and ramadan
The following case highlights the potential risks of both hypoglycaemia and renal impairment in Muslim patients with type 2 diabetes who fast during the lunar month of Ramadan from sunrise to sunset. A 66-year-old Muslim man with type 2 diabetes treated with metformin and gliclazide, was fasting during the daylight hours of Ramadan. He was admitted with symptomatic hypoglycaemia and acute renal impairment following a short history of diarrhoea. A diagnosis of viral gastroenteritis and dehydration secondary to prolonged fasting was made. The hypoglycaemia was precipitated by a combination of fasting, gliclazide use and acute renal impairment. Although the choice of fasting rests with an individual, the risks could be minimised through patient education and medical assessment before Ramadan. It is also important for all healthcare professionals to be aware of and respect this religious obligation in order to provide appropriate care for patients with diabetes who choose to fast during Ramadan.
- Hypoglycaemia in a non-diabetic: vague non-specific symptoms but a serious underlying pathology
We describe a case of severe symptomatic hypoglycaemia in a nondiabetic patient presenting to A&E. The associated discussion outlines the management of hypoglycaemia and explores the differential diagnosis, investigation and localisation of a potential insulinoma.
- Mediastinal parathyroid adenoma
A 42-year-old lady of Asian origin has been a regular attendee at urology outpatients over the past 18 months with intermittent hospital admissions due to recurrent renal stone (calculi) disease. Due to the number and nature of the stone burden, the decision was made for percutaneous nephrolithomy (PCNL) to be performed.
- Acute otitis externa
This case based discussion centres around a 95-year old female presenting to A&E with acute otitis externa (AOE) who develops perichondritis as a consequence of the initial infection. The case looks at the clinical assessment and treatment of the condition and discusses the ongoing management and follow up.
- Recurrent unilateral epistaxis
Epistaxis is a common medical complaint. Although the exact incidence is unknown, it is thought to occur in 60% of people at some point in their life, 6% of which will seek medical advice (1). Epistaxis can occur in all age ranges, from children through to the elderly. The spectrum of clinical manifestation extends from mild intermittent blood-stained rhinorrhoea to life threatening haemorrhage. Local and systemic factors can contribute to the aetiology of epistaxis. Many cases of epistaxis can be controlled by local measures, such as pinching the nostrils and ice packs to the head. However, some cases require nasal cautery, packing or surgical ligation or radiological embolisation of arteries. We present a case of a 79-year old gentleman with an acute presentation of recurrent unilateral epistaxis. It is essential to speedily elicit a clear history. After appropriate resuscitation, endoscopic examination allows identification of responsible vessel and effective management.
- Management of a solitary thyroid nodule
This article on good clinical care focuses on the diagnosis and management of thyroid lump. We shall illustrate a case example and discuss the management of patient in this case and the approach to diagnosis and management of a solitary thyroid nodule on the basis of imaging and cytology findings.
- Otosclerosis
This case based discussion relates to a patient who presented with impaired hearing. The key features in diagnosis, investigation and management of otosclerosis will be discussed.
- A simple ear infection gets complicated
12 month old girl present to accident and emergency with a history of ear ache and fevers. She is found to have reduced consciousness and evidence of mastoiditis. She undergoes a CT which shows evidence of further intracranial complications and goes to theatre for surgical management of this.
- Management of an otological emergency: lateral sinus thrombosis
A thirty four years old man presented with a four weeks history of right ear discharge associated with right otalgia, fever, headache, and neck stiffness. Examination showed slight discharge with an inflamed right ear drum and no neurological signs apart from neck stiffness. A CT scan revealed right transverse sinus thrombosis. He was treated with intravenous antibiotics and heparin. He went on to develop a pyopneumothorax secondary to septic emboli, which was treated successfully. Follow up after several months showed chronic right middle ear disease.
- Noise-induced hearing loss
A patient presented with bilateral hearing loss with tinnitus. The discussion focuses on the key points in the history, the investigations and how to manage noise-induced hearing loss (NIHL).
- Facial palsy
Facial palsy can commonly present at the GP surgery, ENT clinic or emergency department. The loss of muscle tone, symmetry, and dynamics compromises facial aesthetics, non-verbal communication and eating; it also risks damage to the eye; thus causing physical morbidity to the patient. Moreover, these can result in significant social and psychological morbidity. It is important to examine the facial nerve in head and neck patients as well as those with otological or neurological complaints. This article describes a case of facial nerve palsy. It explains how to assess a patient presenting with facial nerve palsy, the management and the relevant anatomy of the facial nerve.
- Epistaxis
A 59-year-old man presents to the A&E department with a right sided epistaxis. He states that the bleeding started in the early hours of the morning and would not stop with simple nasal pressure. He is unable to estimate how much blood he has lost, but brings with him a number of blood-stained tissues. He mentions that he has had some smaller bleeds recently but did not need to seek medical assistance. He has a history of hypertension and takes aspirin. He is actively bleeding on presentation.
- Facial nerve palsy
This case based discussion focuses around the presentation of a pregnant lady to the A&E department with sudden onset left-sided facial paralysis. The key aspects of the foundation curriculum that will be covered include good clinical care (eliciting a history, examination, diagnosis, clinical decision making, safe prescribing); maintaining good medical practice (lifelong learning, evidencebased guidelines); relationship with patients and communication skills; and working with colleagues (communication with colleagues, teamwork for patient safety, interface with different specialties).
- Management of orbital cellulitis
A 6-year-old girl presented to accident and emergency with 2 days history of increasing swelling of left eye, fever, headaches and 1 day history of inability to open her left eye. Examination revealed left periorbital and lid oedema and restricted eye opening. A clinical diagnosis of periorbital cellulitis was made and she was treated with intravenous antibiotics, analgesics and topical nasal decongestants. Regular monitoring of her vision, extraocular movements and clinical symptoms were included in her observation chart. Subsequently, she developed conjunctival chemosis and restricted and painful left eye movements. Since the clinical signs worsened over 24 hours despite conservative medical treatment, a scan was requested. CT scan confirmed a small subperiosteal collection with ethmoid and maxillary sinusitis, needing further intervention. This case based discussion highlights potential serious complications of orbital cellulitis and the importance of early diagnosis and timely management to prevent fatal complications.
- Otological malignancy
Malignancies of the ear and temporal bone are exceedingly rare and usually present with symptoms like chronic otorrhoea and otalgia that are common to benign conditions like otitis externa. There is a wide range of histologically distinct tumours with specific patterns of spread, of which Squamous cell carcinoma (SCCs) and Basal cell carcinoma (BCCs) are the most common. The gold standard of treatment is surgery, with adjuvant radiotherapy for high stage disease. 5-year survival rates are between 80-100% for early disease and 35-50% for late disease. Prognosis is influenced by tumour site, facial nerve involvement, lymph node metastases and positive resection margins. The key role of the foundation doctor is to be alert to the recognition of persistent ‘benignlooking’ symptoms unresponsive to conservative treatment, which may be the presenting feature of an underlying malignancy.
- Peritonsillar abscess
Peritonsillar abscess or ‘Quinsy’, is a common complication of acute tonsillitis. It is one of the commonest reasons for acute admission to the ENT ward in the UK. The main objective of this case based discussion is to provide foundation trainees with a synopsis of the aetiology, pathogenesis, differential diagnosis and management of peritonsillar abscess. Various evidence-based management options will be discussed.
- Sinonasal tumours
This paper is a case discussion around the topic of sinonasal tumours. It is based on the case of a 62 year-old female who presented to the Head and Neck clinic with symptoms of left sided nasal obstruction and blood stained left nasal discharge. She was diagnosed with squamous cell carcinoma (SCC) of the left nasal vestibule and this was treated with surgical excision. This paper focuses on the clinical assessment of patients presenting with symptoms suggestive of nasal tumours, including how a focused history and examination should be conducted. The investigation and management of these patients is discussed, whilst referring back to details of the original case to illustrate each point.
- The painful ear: assessment and management
Ear pain, or otalgia, is a common symptom encountered throughout a variety of hospital based specialities. In this paper the causes of otalgia, anatomy, investigations and basic management of common and important underlying conditions are discussed in order to provide junior doctors with a systematic framework for approaching the patient with otalgia.
- Unusual ENT cases
ENT medicine covers a variety of common pathologies from rhinosinusitis to tonsillitis. However it also encounters interesting and difficult cases that require prompt diagnosis, efficient investigation and effective management. As foundation doctors the presentation and management of such conditions can be challenging but maintaining a high clinical suspicion of unusual symptoms, signs and results with a willingness to seek expert, senior help will ensure optimum patient care. In this article some rare but noteworthy cases will be discussed, alongside a brief overview of literature surrounding the conditions.
- Rhinitis and its management
A 19-year-old female presented with perennial symptoms of sneezing, rhinorrhoea, itching and nasal congestion. Symptoms were worse in the morning. Oral antihistamine was started by the GP but did not provide significant relief.
- Prescribing intranasal drugs
A 56-year-old gentleman presents in the ENT outpatients with a long history of worsening nasal obstruction and hyposmia. He has a history of asthma and has been taking inhaled bronchodilators only. He has a strong history of allergies, which are especially severe in the summer months. On examination you are able to visualise an inflamed nasal mucosa typical of allergic rhinitis. How can this gentleman be managed medically?
- Management of the discharging ear
A 6-year-old boy presented to his GP with a 24-hour history of left ear discharge. His mother said that he suffered with a common cold 10 days previously and that a few days later his teacher noticed he was not paying attention in class. Two days prior to presentation he started complaining of left earache, reduced hearing and fever which responded to paracetamol. On the morning of presentation she noticed some blood and pus on his pillow. The child said that the earache had settled. The ear, nose and throat (ENT) examination revealed a left purulent otorrhoea with central perforation and an inflamed tympanic membrane. Rinne’s tuning fork test was negative on the left side whilst the Weber’s test localized to the left. The rest of the examination was unremarkable. The patient was treated conservatively for acute otitis media with analgesia and his mother was asked to ensure his left ear was kept dry for 2 weeks until review.
- Stridor in children
An 11-month-old child was brought to the emergency department at 01:00 hrs. His parents were woken by a loud barking noise and found the child crying in his cot. He was pyrexial (37.8°C), had a respiratory rate of 28 per minute and oxygen saturation of 99% on air. There was mild sub-costal recession and some stridor when agitated. How would you manage this patient?
- Painful and increased swelling in the lower neck
You are asked to see a 24-year-old man with an 8 week history of a persistent, increasing painful swelling in the lower neck. He had no other symptoms, in particular, any ENT or constitutional symptoms. Of note, in the past he had noticed a discharge from this area which settled spontaneously. He had no other past medical history of note. He was a non-smoker and drinker. You examine the patient and fit nd a well-looking man, who is apyrexial. He has a flu uctuant swelling measuring 5 cm in the lower midline of his neck. He has no other lumps to feel in the neck.
- Management of an otological emergency
A 25-year-old man with a long history of otitis media with effusion presented with a right-sided facial nerve palsy and ipsilateral facial swelling. Examination revealed complete facial nerve palsy and erythema and swelling over the right side of his face. Otoscopy showed a tympanic perforation and an attic polyp. A working diagnosis of cholesteatoma was made and confirmed by CT. He was treated with intravenous and topical antibiotics and systemic steroids. The cholesteatoma was removed by urgent modified radical mastoidectomy and the facial nerve was decompressed. The presentation, investigation and management of this patient highlight serious complications arising from cholesteatoma and the importance and potential success of swift diagnosis and treatment. Points for consideration raised by this case include facial nerve paralysis, acute and chronic otitis media and cholesteatoma.
- Acute otitis media and unilateral facial weakness
This case-based discussion centres on a 9-month-old boy presenting to A&E with acute otitis media and unilateral facial weakness. It outlines the clinical assessment, investigations and treatment of such a case and discusses the causes and complications relating to this diagnosis.
- Investigating deafness
This case-based discussion focuses on the investigation of a patient presenting with deafness in a Primary Care setting and highlights the most important steps of the assessment process with the intention of guiding Foundation Doctors in their patient management.
- Pharyngeal pouch / zenker diverticulum
This case based discussion focuses on the presentation and management options of a pharyngeal pouch in a 72-year-old woman.
- Acute otitis media in a young child
This case-based discussion looks at the presentation of acute otitis media (AOM) in a young child. It will focus on the key points to look out for when taking a history and performing an examination, potential differential diagnoses and the management of the patient.
- Flexible nasendoscopy
We present a case history of a patient presenting with a sore throat and odynophagia, who underwent a flexible nasendoscopy to diagnose epiglottitis. The practical procedure of flexible nasendoscopy is reviewed; focusing on explaining the procedure and gaining consent, along with the indications, contraindications and complications of nasendoscopy.
- Assessment, diagnosis and treatment of facial palsy
This case-based discussion focusses on a patient who presented with a leftsided facial palsy. The assessment, differential diagnoses and treatment of the patient's facial palsy will be discussed, together with an overview of the relevant anatomy.
- Acute assessment and management of epistaxis
Epistaxis is the most common ENT emergency, affecting 60% of the population in their lifetime, with 6% presenting to hospital1. It often presents to other specialties, including A&E, medical and paediatric disciplines. The objective of the article is to guide foundation trainees in the acute assessment and management of epistaxis.
- Tonsils and adenoids: sleep-related breathing disorders in children
Sleep-related breathing disorders (SBD) in children are common, ranging from snoring, which is a relatively benign and common condition, to obstructive sleep apnoea (OSA) at the other end of the spectrum, typically characterised by oxygen desaturation, reduced oronasal air flow and paradoxical movement of the chest and abdomen (see Figure 1) (1). In the UK, 12% of 4-5 year old children snore on a regular basis and the typical affected child who suffers from SBD is aged 2-5 years old (2). Up to 3% of children experience episodes of intermittent complete upper airway obstruction or OSA, which is the most extreme form of SBD (3). The purpose of this article is to highlight SBD in children to FY2 trainees as a common but serious condition which presents to general practitioners (GP), paediatricians and otolaryngologists, with a view to guiding trainees through its diagnosis and management.
- Assessment and management of adult acute upper airway obstruction
A patient presented with acute onset shortness of breath and stridor due to a large tumour of the larynx. The initial assessment, investigation and treatment of patients presenting with acute upper airway obstruction is discussed. Systematic, clear guidance is presented for the physician involved in the management of this often frightening, emergency clinical presentation. Further, specialist ENT interventions relevant to the case report are then discussed in context.
- Drooling child: Assessment in accident and emergency
Presentation of a drooling child in acute setup is not uncommon and is a serious airway problem. The majority of these cases are managed by senior doctors in the respective department i.e. paediatrics, accident and emergency, anaesthetics and otorhinolaryngology.
- Convulsion/seizure in pediatric populations: a common presentation but a rare outcome
Autism is a condition characterized by impaired cognitive and social skills associated with compromised immune function. A 6 year old girl presented to us with impaired cognitive and social skills associated with compromised immune function leading to suffer from recurrent chest infection, seizure, intolerance to food and various chemical products. This poor little girl has had completed the vaccine regime as per immunization calendar in Spain. She has been suffering from the symptoms and signs which fulfill the criteria for the diagnosis of autism and obviously, she has been exposed to aluminium (vaccines and/or environmental source) and acetaminophen to control fever and pain as she suffered from recurrent infection. The most important fact is that the test for toxic elements in her hair has shown significantly elevated level of aluminium.
- Food induced idiopathic hypertension and oedema
We present a case of food induced intractable idiopathic hypertension and oedema, responding to an exclusion diet followed by provocation of symptoms on reintroducing the excluded foods. The patient was subsequently treated with intradermal, low dose, antigen-specific immunotherapy to the identified foods which allowed controlling both blood pressure and oedema despite withdrawal of all pharmacological therapies. The possible role of food intolerance in the development of hypertension and oedema and its treatment are discussed.
- Hypertriglyceridaemia
This study describes the case of a 45-year-old man who suffered from hypertriglyceridaemia in spite of following a low-fat diet. The effects of a lowfructose diet on hypertriglyceridaemia are described. Cardiovascular genetic testing was also carried out, which casts further light on our understanding of this condition.
- Nervous system symptoms
This is a case summary based on a 44-year-old female patient who presented with nervous system symptoms at the age of 32. This paper highlights her clinical history, examination, investigations and the use of an environmental medicine-based approach to her management including, in particular, the efficacy of nutritional medicine combined with low-dose immunotherapy
- Positive effects of low-dose immunotherapy in a rheumatoid arthritis patient
Rheumatoid arthritis is an autoimmune systemic disease of unknown aetiology involving chronic polyarthritis and affects 2% of the economically active population. This paper discusses the case of a 39-year-old woman who presented with particular flaring-up of her arthritis at ovulation and in the second half of her menstrual cycle when oestrogen levels are high. At these times she became very fatigued, trembled internally, became easily confused and overtired, and had an acute reaction with uncontrollable muscle twitch and spasm. She also felt very nauseated and her limbs became weak. The patient was managed by low-dose immunotherapy (LDI) desensitising her for oestrogen, aerobic and anaerobic bacteria. The patient also switched over to a progesterone-only pill in an attempt to override her hormonal cycle and suppress ovulation. Desensitisation with LDI and self-vaccination treatment brought back the patient’s energy, calmed her stomach and improved her arthritis.
- Sudden onset headache in a Lyme patient
This case study discusses a 55-year-old woman who presented with sudden headache. The patient was diagnosed with Lyme disease using the Western Blot IgM and IgG that showed positive band 41 kDa (Kilodalton) for Borrelia. She was treated with the antibiotic cefuroxime axetil, 500 mg orally twice daily for four weeks following which the headache disappeared.
- Ethics & good communication
The case of Mr M discusses a 94 year old gentleman who unfortunately passed away. Prior to his arrest he did not have a DNAR order completed and was therefore resuscitated, surviving five days in a coma before dying. There were multiple errors in communication throughout his care which ultimately lead to more distress for the patient and family, as well as a serious incident being filed.
- Treating Crohn's disease with diet and antifungals
The case of a patient with Crohn's disease is reported where treatment with dietary measures as well as intraluminal anti-fungal medication for underlying changes to the gut flora resulted in clinical and radiological remission. The potential role of the microbiome in particular the gut microflora is discussed in the context of inflammatory bowel disease. In particular, it is speculated that due to the high burden of antibiotic use both in medical practice and through exposure to food produced on farms where routine use of antibiotics enter the food chain, fungal type dysbiosis may compound the symptoms and progression of inflammatory bowel diseases such as Crohn's disease. It follows that treatment with simple dietary protocols and antifungals may in a subset of patients alter the clinical course and natural history of the condition.
- Acute abdominal bleeding
A 72-year-old male was referred to the surgical admissions unit for assessment of a 2-day history of right upper quadrant pain. He also complained of worsening ankle and abdominal swelling. Past medical history was unremarkable and he drank a minor amount of alcohol. On examination, he was tender in the right upper quadrant with a positive Murphy’s sign. Palmar erythema and numerous spider naevi were also noted as well as bipedal oedema and shifting dullness, consistent with the presence of ascites. Examination of the respiratory and cardiovascular system was unremarkable. Ultrasonography confimed the presence of ascites with biliary tree appearances in keeping with acute cholecystitis. The patient was treated conservatively with antibiotics and analgesics. However, his in-patient stay was complicated by massive haemetemesis.
- A case of fulminant liver failure
A 75-year-old retired miner with diffuse pulmonary fibrosis presented to the medical assessment unit with a 24-hour history of confusion and agitation. He had been admitted to the hospital 4 weeks before with chest pain. Acute cardiac and respiratory caused were excluded and he was discharged from the unit on Paracetamol, 1g 6-8 hourly as required. Examination demonstrated jaundice, asterixis and Grade III hepatic encephalopathy. He had no stigmata or signs of chronic liver disease or its complications.
- Tests for Helicobacter Pylori
A 37-year-old man presents to the GP surgery with recurrent episodes of dyspepsia unresponsive to self-medication with over-the-counter Gaviscon and ranitidine. On direct questioning there is no history of weight loss, vomiting, haematemesis or dysphagia. How would you proceed to investigate this patient?
- Prescribing in liver disease
You are asked to see a 56-year-old gentleman with confirmed alcoholic liver cirrhosis who is complaining of increasing abdominal discomfort and bloating.
- Management of massive (variceal) GI bleeding
A 56-year-old man with a long history of alcohol abuse was found by his wife collapsed in his home covered in malaena. On arrival paramedics found him to be haemodynamically unstable with a pulse of 120 and BP of 70/40. In the ambulance he vomits approximately 150 mls of fresh blood. On examination in A&E he has multiple stigmata of chronic liver disease. His Glasgow Coma Scale score is 9/15. Initial blood results show a haemoglobin of 7g/dl, platelets of 65 (x109/l), an albumin of 23 g/l, and an INR of 2.1. You are called to see him urgently. How would you manage this patient?
- Management of upper GI haemorrhage-variceal bleeding
A 47-year-old property manager presents to A&E with a 6-hour history of large volume fresh haematemesis associated with a feeling of light-headedness. He gives a history of significant alcohol consumption of 60 units per week for the last 15 years. There is no other past medical history of note. The patient is on no regular medication and has no known allergies. Clinical examination reveals a tachycardia of 120 bpm and a blood pressure of 90/60mmHg (with a postural drop of 25mmHg). The patient is pale and jaundiced and has numerous stigmata of chronic liver disease including numerous spider naevi and Dupuytren’s contractures bilaterally. There is abdominal distension with flank dullness, in keeping with ascites and rectal examination confirms the presence of melaena.
- Management of upper GI haemorrhage-variceal bleeding
A 47-year-old property manager presents to A&E with a 6-hour history of large volume fresh haematemesis associated with a feeling of light-headedness. He gives a history of significant alcohol consumption of 60 units per week for the last 15 years. There is no other past medical history of note. The patient is on no regular medication and has no known allergies. Clinical examination reveals a tachycardia of 120 bpm and a blood pressure of 90/60mmHg (with a postural drop of 25mmHg). The patient is pale and jaundiced and has numerous stigmata of chronic liver disease including numerous spider naevi and Dupuytren’s contractures bilaterally. There is abdominal distension with flank dullness, in keeping with ascites and rectal examination confirms the presence of melaena.
- Ulcerative colitis
A 28-years-old Pharmacist presents to the acute medical team with a 6 week history of increasingly severe bloody diarrhoea. Over the last week her bowel frequency has reached 12 times a day, and she complains of generalised abdominal cramps. She has also noticed a generalised sensation of joint aches. She gives a history of visiting India 3 months prior but is otherwise fit and well, with no prior medical history. She takes the oral contraceptive pill and her boyfriend is well. She doesn’t smoke and drinks minimally. There is no pertinent family history.
- A logical approach to management of a common surgical emergency
Large bowel obstruction is a common and very familiar surgical emergency. About 15-20% of patients with colorectal cancer present this way; of these, about 70% tend to be above 70 years of age. Approximately 20-25% of patients have distant metastasis at presentation and a significant of them may have other comorbidities. Management of these patients therefore requires very thorough and meticulous care.
- Antibiotics and bowel preparation in colorectal surgery
You are asked to see a 68-year-old gentleman with a history of an episode of heavy fresh bleeding per rectum and change in bowel habit to constipation. He is on aspirin and clopidogrel following his coronary stenting a year ago. He is also known to have diabetes mellitus type 2 on metformin and gliclazide. He is apyrexial; pulse rate is 96/minute and blood pressure is 124/71. There is mild tenderness in the left iliac fossa. Digital rectal examination and rigid sigmoidoscopy had revealed altered blood in the rectum. You note that his recent haemoglobin is 7.2 g/dl; white cell count is 13.2 and INR is 1.2.
- Colorectal carcinoma
A 78-year-old male presented to Accident and Emergency department with a 4-day history of abdominal distension, vomiting and constipation. He had a background history of known diverticular disease. In the last 6 weeks, he had increasing symptoms of loose and frequent bowel motions. He had a history of hypertension and migraine. His sister had a right hemicolectomy for caecal adenocarcinoma at age 65 years. His initial observations showed a temperature of 37.5C, heart rate 110/min, blood pressure 158/87 and respiratory rate 16/min. Blood tests showed a haemoglobin 15.3 g/dl; WBC 14×10^9/L; platelets 667×10^9/L; urea 9.4 mmol/L and a creatinine 123 µmol/L. His plain abdominal X-ray showed signs of large bowel obstruction. He subsequently had a CT scan of the abdomen which showed an obstructing sigmoid carcinoma with no evidence of perforation or metastatic disease. Following his initial resuscitation, he had a colonic stent inserted to relieve the obstruction. Four days later, he had an elective anterior resection with primary anastomosis. He was discharged home 1 week later. Histology confirmed a Dukes B adenocarcinoma of the sigmoid.
- Acute appendicitis
A 24-year-old girl presents with a 36-hour history of abdominal pain. This pain had become increasingly severe and was colicky in nature but with intermittent sharp episodes, and was felt mostly in the epigastrium. With time the pain became more generalised. She felt nauseous and vomited but had no haematemesis. She had lost her appetite over 2 days. Her bowels had not opened for 2 days, but prior to that she had had normal movements with no associated blood. She was passing only small amounts of urine, but had no dysuria or cloudy urine. She was 2 weeks past her last menstrual period and was taking the oral contraceptive pill but no other medications. She had had no previous abdominal operations.
- Acute cholecystitis
A 39 year old housewife is admitted via A/E with a 12 hour history of severe epigastric pain and vomiting. She had had 2 previous attacks in the last 3 months which she had put down to indigestion, had not called her GP and which had settled overnight. One year previously she had given birth to twins and during this pregnancy had suffered similar discomfort. There was no past medical history, she was otherwise fit and well. She was on no medication, no known allergies or significant family history.
- Latrogenic abdominal pain
An 82-year-old woman was admitted from the outpatient clinic for evaluation of progressive breathlessness over the preceding four months. Examination revealed bilateral pitting oedema from the ankles to the knees, with raised jugular venous pressure. A tricuspid pansystolic murmur was noted on auscultation. Past medical history revealed atrial fibrillation, type 2 diabetes mellitus, hypertension and chronic renal failure. She had been investigated for iron deficiency anaemia four years previously, which was attributed to angiodysplasia of the midgut, and treated by electro-cauterisation. At the time of admission she was on gliclazide, bumetanide, diltiazem, pioglitazone, losartan, simvastatin. Anticoagulation for atrial fibrillation was withheld because of the previous history of angiodysplasia.
- Rigid sigmoidoscopy and flatus tube insertion for sigmoid volvulus
Sigmoid volvulus is a common cause of large bowel obstruction in the elderly and in many cases it can be recurrent. If promptly diagnosed, it can be safely treated by performing a rigid sigmoidoscopy and then inserting a flatus tube. Very often, this would provide almost instant relief for the patient. After reading this article, the reader would have a good understanding of how to perform a rigid sigmoidoscopy and insert a flatus tube. They would also have an understanding of the various indications and contra-indications for this procedure.
- Gastro-oesophageal reflux
Mr X is a fit and well 54 year old gentleman, who has suffered from postprandial dyspepsia for approximately 2 years. Previously relieved by simple antacids, the pain has become progressively worse and now occurs at night as well as after meals. His general practitioner had prescribed him a course of omeprazole.
- Bowel fistula
Gastrointestinal internal fistulae are abnormal passages or openings that connect the gastrointestinal (GI) tract with another organ or space caused by trauma, disease or congenital anomaly. In relation to Crohn’s disease they specifically exclude perianal fistulae. Internal fistulae occur in 5-15% of patients with Crohn’s Disease and approximately one-third of these patients require surgery. There is a paucity of controlled data on which to base recommendations for the treatment of internal fistulae in Crohn’s Disease. We discuss a case of GI fistula.
- Short bowel syndrome
The incidence and management of short bowel syndrome is increasing due to advances in bowel surgery, postoperative care and nutritional support. This case based discussion focuses on the management of post-operative hydration and nutrition complications of one such patient who underwent extensive small bowel resection for perforated ischaemic bowel.
- Medical pitfalls in IBS management
A patient is described with a history of abdominal symptoms. The discussion focuses on the clinical features that distinguish a functional gastrointestinal disorder from organic disease, the alarm features that should prompt a referral to a gastroenterologist and the management options for a patient with irritable bowel syndrome.
- Alcoholic liver disease
This case based discussion follows the clinical course of a 42 year old man who drinks alcohol to excess and presents with deranged liver tests. It will focus on the assessment and diagnosis of liver disease caused by alcohol misuse and the management of clinical problems related to this disease process.
- Metformin intolerance
This case-based discussion looks at an elderly patient with metformin intolerance presenting with nausea and vomiting shortly after eating. It will focus on the key points to look out for when taking a history and performing an examination, potential differential diagnoses and the management of the patient.
- Four cases in gastroenterology
We present four cases of in gastroenterology, and a picture quiz with each.
- Acute severe ulcerative colitis
Acute severe ulcerative colitis will affect 15% of UC patients at some point in their disease course.1 Twenty percent of first attacks of UC are 'acute severe' in nature (1). The goal of medical therapy is to avoid colectomy, while preventing complications of disease, side effects of medications and mortality. In addition to medical therapies, optimisation of the overall supportive care of patients with acute severe UC is essential. In this article we present a typical case of acute severe UC presenting on a general medical take. The case has been used to illustrate the diagnosis, investigations and immediate management of a patient with acute severe UC.
- Investigating malabsorption
This case-based discussion focuses on a previously well 53 year-old man presenting with symptoms suggestive of malabsorption and discusses the investigation, differential diagnosis and management of malabsorption.
- Ascites and non-alcoholic steatohepatitis (NASH)
A 58 year old lady presented to the Emergency Department with a 2 month history of lethargy and increasing shortness of breath. She had also noted abdominal swelling for the past 3 weeks, which her GP has told her is "fluid in her abdomen". Her ankles have also become swollen.
- Upper gastrointestinal cancer
Oesophageal and gastric cancer are among the leading causes of cancer death in the United Kingdom (UK). This article provides an insight into the epidemiology, presentation, diagnosis and management of these conditions. It focuses specifically on the most common histological types of upper gastrointestinal malignancies, those of oesophageal squamous cell carcinoma and oesophageal adenocarcinoma and gastric adenocarcinoma.
- Management of colorectal cancer: focus on population screening
Mrs CB, a 60-year-old female, presented to her GP with a 4-month history of tiredness and loose stools, having had a long life history of tendency to constipation, and weight loss (6 kg in the past 6 months). She has a family history of cancer though not colonic. Her past medical history was irrelevant. Mrs CB's GP suspected a gastrointestinal malignancy and referred her to the local GI department for investigation.
- ERCP and cholangiocarcinoma
A 74-year-old Caucasian woman is referred to hospital on the acute medical take by her GP. She reports a 3-week history of vomiting associated with unintentional weight loss of 3–4kg. Four days earlier the patient's daughter had commented on a yellow discolouration to her skin and eyes, which had since become more pronounced. The patient denied abdominal pain. She commented that her appetite had been poor for a few weeks and she was eating very little. She had noticed dark discoloration of her urine 1 week earlier and when directly questioned admitted her stools had been pale in colour and offensive smelling. She had never experienced similar symptoms in the past.
- Percutaneous endoscopic gastrostomy (PEG)
A 79-year-old lady presented to the A&E with sudden onset dysarthria, dehydration and left-sided weakness. She had a history of previous transient ischaemic attacks and hypertension. She lived alone and was self-caring with a supportive family. On examination she had a dense left hemiplegia and dysarthria. A CT scan confirmed an early right cerebral hemisphere infarct and she was transferred to the stroke ward. Over the next 48 hours, the patient was assessed by the speech and language therapist who concluded that, as a result of her stroke, she was at significant risk of aspiration from her impaired swallow. A nasogastric feeding tube was passed and feeding commenced. Two weeks later, she was clinically stable with little signs of recovery and was still dysphagic and dysarthric with a hemiplegia. She remained at risk of aspiration according to the speech and language therapist assessment.
- Chronic diarrhoea
A 49-year-old housewife was referred to gastroenterology outpatients with a 2-year history of diarrhoea. The GP letter outlined that she had recently been opening her bowels 6–10 times a day and 1–2 times at night. The diarrhoea was described as watery with no blood seen. There was no relation to dietary factors (milk, bread, etc.) and no history of weight loss. She felt that her symptoms were significantly affecting her life and found it embarrassing to leave her flat. There was no family history of colonic neoplasm or inflammatory bowel disease.
- Traveller's diarrhoea
A previously fit and well 28-year-old doctor develops abdominal cramps and watery diarrhoea five times a day on her honeymoon in Vietnam. She self-medicates with a 3-day course of ciprofloxacin 500mgs bd. On her return home (day 4), she attends her general practitioner complaining that her symptoms have not abated.
- A practical guide to the use of faecal calprotectin testing
Abdominal pain with, or without a change in bowel habit is a common presenting symptom in primary care. A majority of these patients will be suffering from functional bowel disorders including functional dyspepsia and irritable bowel syndrome. Indeed, functional bowel disorders make up a significant proportion of referrals to gastroenterology outpatient clinics (up to 60%) (1). The dilemma in primary care is distinguishing a patient with functional symptoms from one with an underlying diagnosis of inflammatory bowel disease. Up to 50% of patients with a functional diagnosis are referred on for unnecessary endoscopic evaluation (1). Faecal calprotectin is an inflammatory marker, which is released in excess into the bowel when there is inflammation present. It is measured in the stool and has been shown to help in the differential diagnosis of inflammatory bowel disease and irritable bowel syndrome (2).
- Eosinophilic oesophagitis (EoE)
Eosinophilic oesophagitis (EoE) was first described in adult patients in the early 1980's and has since become an increasingly recognised cause of oesophageal dysfunction. It is characterised by symptoms, such as dysphagia and food bolus obstruction, in conjunction with characteristic endoscopic and histological appearances. Treatment usually consists of topical oesophageal steroids, but other therapies are also used. This case-based discussion will include clinical presentation, investigational findings, pathophysiology and management.
- Coeliac disease
Coeliac disease (CD) is a chronic systemic, autoimmune disorder in genetically predisposed individuals triggered by exposure to dietary gluten. Gluten ingestion leads to mucosal inflammation, crypt hyperplasia and villous atrophy. Patients may present with many or no gastrointestinal symptoms and or the consequences of malabsorption including iron deficiency anaemia and osteoporosis. Gluten proteins and related prolamins found in wheat, barley, and rye may trigger autoimmune injury to the gut, skin, liver, joints, uterus, and other organs (1). Histological abnormalities including villous atrophy in small bowel biopsies, is considered the gold standard for diagnosis, and supported by serology. Untreated CD is associated with significant morbidity and an up to 4-fold increase in risk of death. The condition is potentially reversible on a gluten free diet.
- Crohn's disease
A 25-year-old man with a 3 year history of Crohn's disease affecting the small bowel and peri-anal region (fistulae) presents to hospital with abdominal pain. Over the last two weeks he has had several episodes of abdominal pain and vomiting in association with constipation, which all settled spontaneously. Over the last 36 hours his central abdominal pain has worsened and he has been unable to keep any fluids or solids down. His bowels are not opening. He currently takes budesonide and azathioprine and has never had any abdominal surgery. He is an otherwise fit and healthy teacher who smokes 20 cigarettes a day and drinks beer socially.
- A difficult case of Crohn's disease: assessment and management
Crohn's disease (CD) is a chronic inflammatory disease affecting the gastrointestinal tract. The disease is relatively common, and may be encountered by junior doctors working in various specialties. Assessment of disease and patient management may be challenging. Here, we describe a young patient with a new diagnosis of CD following an acute medical admission, and discuss his outpatient journey.
- Blunt pancreatic trauma: an easily missed diagnosis in a young adult patient
This case describes an acute presentation of a young patient with severe blunt abdominal trauma. However, because of her young age and massive physiological reserves, she was able to mask the severity of her signs and symptoms during a thorough physical examination. This resulted in the diagnosis of her pancreatic trauma being initially missed. It was her second presentation to the emergency department, two days later, when the severity of her symptoms and signs mandated an urgent CT scan. This showed a grade III pancreatic and liver trauma. She was managed conservatively at a hepatobiliary tertiary centre, with repeated imaging to check for any complications. She made a good recovery with conservative management.
- Nutritional rescue
Insult is added to physical injury of disease, when malnutrition arises either directly from the underlying disease or from inadequate oral intake. Consequently, the immune response, wound healing, and muscle strength are all weakened. Awareness and early Nutritional intervention can rescue ill patients from this downward spiral. We present two illustrative cases and discuss some practicalities of Intervention.
- The investigation and management of chronic hepatitis B virus infection
Hepatitis B (HBV) is the commonest blood borne viral infection in the world with almost 2 billion people previously infected and 350 million who are currently chronic carriers of the disease. Chronic infection with hepatitis B carries an increased risk of developing liver cirrhosis, decompensated liver disease and hepatocellular carcinoma (HCC). Approximately 600,000 to 1.2 million individuals die each year from HBV due to acute or chronic HBV or HCC. HCC is the 5th commonest cancer worldwide and its incidence is increasing with approximately 300,000 to 500,000 new cases each year (1). Most cases are found in Sub-Saharan Africa, the Far East, the Indian Sub-Continent and increasingly Eastern Europe. Because of air travel and migration, prevalence in Western Europe and North America is increasing. The aim of this article is to provide a framework for investigating and managing the common aspects of chronic hepatitis B infection that foundation doctors will come across in primary and secondary care based on a number of cases highlighted below.
- Common questions from patients with inflammatory bowel disease
Inflammatory Bowel disease (IBD) is a term used to describe chronic conditions that cause inflammation of the gastrointestinal tract. Crohn's disease and ulcerative colitis (UC) are the two most common causes of IBD in the United Kingdom (UK). The incidence of IBD is gradually increasing each year with a current estimated UK prevalence of 4 in 1000 people (1-2). IBD is associated with significant morbidity, with a lifetime cost similar to that encountered following a diagnosis of cancer or heart disease (3). As junior doctors, answering a patient's questions about IBD can be difficult. However, many patients report feelings of humiliation and embarrassment from their symptoms (2). Therefore, being able to discuss IBD inpatients' concerns is an important part of a junior doctor's role. This article seeks to explore some key questions we have been asked whilst working on a gastroenterology ward.
- From diet to surgery: managing obesity
Mrs A is a 55-year-old lady who has presented to her GP with pain in both knees that is there all day long and worse after use. Mrs A weights 85 kg and is 1.53 m tall. She is on medication for hypertension and depression.
- Management of deliberate self-harm in adolescence
Lisa, a 15 year old girl, attends the accident and emergency department with her best friend. She has taken an overdose of eight paracetamol tablets. Her friend has persuaded her to attend. You see her and she consents to a physical assessment and blood tests. However, she is reluctant to discuss the reasons for her overdose. How should you proceed?
- Tests for Helicobacter Pylori
A 37-year-old man presents to the GP surgery with recurrent episodes of dyspepsia unresponsive to self-medication with over-the-counter Gaviscon and ranitidine. On direct questioning there is no history of weight loss, vomiting, haematemesis or dysphagia. How would you proceed to investigate this patient?
- Facial palsy
Facial palsy can commonly present at the GP surgery, ENT clinic or emergency department. The loss of muscle tone, symmetry, and dynamics compromises facial aesthetics, non-verbal communication and eating; it also risks damage to the eye; thus causing physical morbidity to the patient. Moreover, these can result in significant social and psychological morbidity. It is important to examine the facial nerve in head and neck patients as well as those with otological or neurological complaints. This article describes a case of facial nerve palsy. It explains how to assess a patient presenting with facial nerve palsy, the management and the relevant anatomy of the facial nerve.
- Lumps in the neck
Miss X, a 30-year-old secretary, presented to a GP clinic with a lump in her neck just to the right of the midline. She said she had noticed the lump for several months and it had been very gradually increasing in size, so she decided to have it checked as it was now in her opinion cosmetically unfavourable and catching on some of her clothing. She was otherwise asymptomatic and had no significant family history. On examination, a 2 cm firm lump was palpated in the anterior triangle just to the right of the midline. It moved with swallowing, was not fixed to the skin and had a smooth surface with a regular, well-circumscribed border. It was non-tender and did not transilluminate. A small palpable superior cervical lymph node was also discovered on the same side. Thyroid function tests were requested which were normal and she was thus referred to the rapid-access neck lump clinic as an urgent referral (2 weeks). There she had ultrasound guided fine-needle aspiration biopsy of the lump. The histopathologist reported cells with pale, empty looking ‘Orphan Annie’ nuclei and psammoma calcification. She was referred to an endocrine surgeon. What do you think was the likely diagnosis and how do you think it was treated?
- Systolic hypertension
Systemic hypertension is very common amongst adults, and is a major risk factor for cardiovascular events. Isolated systolic hypertension is the most common variant in the elderly, making up sixty percent of the cases in this age group. This case demonstrates the assessment of a patient presenting with newly diagnosed isolated systolic hypertension; including a full history, examination, routine investigations and grading of cardiovascular risk. Management is based on a combination of lifestyle measures, in this case followed by drug treatment. For introduction of medication a step-wise algorithm is used, aiming to combine drugs in the most logical way to maximise the fall in blood pressure. Systemic hypertension requires lifelong follow up and the majority of patients will need combinations of medications to adequately treat the condition.
- Women's health in general practice.
This case based discussion focuses on contraceptive options for an older woman in a primary health care setting. 'Careful assessment and consideration of the wider issues for women's health are required and well provided for in general practice.
- Diagnosing dementia in primary care
Dementia represents a big diagnostic challenge for primary care health professionals as it is often insidious in onset and can present with varied symptoms and signs. The cost of care for people with dementia in the UK is greater than the combined annual expenditure on heart disease, stroke and cancer, combined. An early diagnosis of dementia is crucial as this enables patients and their families to seek early and appropriate support from medical and psycho-social services, significantly improving morale and delaying the need for 24 hour care (1).
- "Oh, by the way Doctor" syndrome.
Doctors frequently explore a patient problem before determining the full spectrum of the patient's concerns. They often redirect the patient's initial description of concerns. This leads to incomplete initial description and raises the chance of late-arising concerns and missed opportunities to gather potentially important data. Uncovering the patient's agenda from the outset takes little time, yields important data and improves the efficiency of the consultation. The authors of this article spent some time in General Practice during their foundation training. They aim, through this article, to share their experience with trainees in General Practice and help them solicit the patient's hidden agenda early in the consultation to avoid the above "syndrome".
- Diagnosis and management of anxiety and depression in patients with physical illness
Patients with physical illnesses have higher rates of depression and anxiety, particularly those with a history of mental illness. Physical and psychological co-morbidity are associated with a poorer physical outcome and an increased use of health care resources. Foundation doctors play an important role in identifying patients with anxiety and depression in the context of physical ill health. This can be achieved by observation and careful enquiry about psychiatric symptoms. We describe a case of a patient whose initial recovery and rehabilitation was hindered by anxiety and depression.
- Non-steroidal anti-inflammatory drugs overdose
This case based discussion focuses on a 67-year-old male retired truck driver presenting with severe abdominal pain, haematemesis and persistent vomiting due to NSAID (non-steroidal anti-inflammatory drugs) overdose and discusses the assessment, differential diagnosis and treatment of NSAID toxicity, focusing on measures to prevent recurrence.
- Management of falls in elderly patients
A 70-year-old lady presents to the clinic after an attendance at the Emergency Department with a fall. This discussion focuses on medications that can cause falls, the importance of considering osteoporosis risk and suggests non drug strategies to prevent falls in the future.
- Intra articular knee injection
A 56-year-old plumber with a BMI of 35, presents to your GP surgery with pain in his left knee. He reports that the pain is worse after work and when walking up stairs. He also comments that his knee feels stiff when sitting down and that he has pain when he starts to walk after resting. He reports that the knee becomes swollen after he has been kneeling for prolonged periods of time. He cannot recall any injury to his knee and is otherwise fit and well. Despite conservative treatment with non-steroidal anti-inflammatory medication and physiotherapy his pain has not settled.
- Stroke
This scenario follows the case of a 65-year-old gentleman who presents with stroke, and discusses both acute and long-term management of such patients. It also provides guidance on transient ischaemic attacks and how to risk stratify patients to determine whether they require immediate inpatient or early outpatient assessment.
- Cardioversion
A 69-year-old practicing dentist was referred by his GP with a 6-month history of mild exertional dyspnoea and a newly detected systolic murmur. He was still able to play 18 holes of golf using a motorised trolley and had no symptoms at rest.
- Supervising an exercise treadmill test
The exercise treadmill test, usually performed to a graduated routine known as the Bruce protocol, has been a standard test for investigating chest pain and ischaemic heart disease (IHD) for many years and is still very widely used. As a Foundation Year colleague you may be asked as part of your programme in cardiology or acute medicine to assist with the supervision of these tests. When used properly they are easy to do, informative and a very useful contribution to the diagnosis and subsequent treatment of patients with ischaemic heart disease. In this short paper, we have tried to summarise the indications for treadmill testing, the pretest contraindications to look out for, the test itself, what constitutes a positive or negative test and the possible complications. It is by necessity a brief run-through and further reading is recommended below. The section about the test itself has been written by a senior cardiac physiologist and a consultant nurse. When supervising a test, you should always be accompanied by a well-qualified cardiac physiologist or nurse and do not feel any qualms about asking them for help and advice. Many of them have supervised literally thousands of tests.
- Secondary prevention after MI
A 40-year-old lorry driver presented to the Emergency Department an hour after onset of central chest pain. He was a smoker with a family history of coronary artery disease. His 12 lead electrocardiogram confirmed an acute anterolateral ST elevation myocardial infarction (STEMI). Following intravenous morphine for analgesia and anti-emetics, he underwent immediate primary percutaneous coronary intervention (PCI) with preoperative loading doses of aspirin and clopidogrel, as well as an intravenous bolus dose of heparin.
- The patient with syncope
A 55-year-old black male experienced an episode of loss of consciousness while attending a funeral in Trinidad. He had flown from the UK the day before and although a little "jet-lagged" was feeling his normal self. Shortly after the ceremony he found himself in a collapsed state in the toilets of the hotel at which he was staying. He had no recollection of the events surrounding his circumstances and was not aware of any warning or aura. He assumed he had possibly had too much to drink or had simply fainted. He attended a local hospital, to check that nothing more serious was responsible. There was no shortness of breath, ankle swelling or chest discomfort.
- Non-specific symptoms in a patient with valvular heart disease
A 46-year-old man presented to our medical assessment unit with a 3-week history of general malaise, muscle aches, night sweats, decreased appetite and a sore throat. He had been lost to follow-up at his local cardiology department with a diagnosis of aortic regurgitation (severity unknown). He had no other past medical history and was on no regular medication. Of note, his son had been diagnosed with a bicuspid aortic valve.
- Management of non-ST elevation acute coronary syndrome
A 62-year-old manual worker presents to the A&E department with a 2-hour history of central chest pain radiating to both arms. His pain subsided after being given sublingual glyceryl trinitrate and aspirin 300mg in the ambulance. Prior to his admission he smoked 20 cigarettes a day for over 40 years. Examination was unremarkable.
- Management of hypertension in primary care
Mr Smith is a 59-year-old Caucasian gentleman, who presents to your GP clinic for the third time with a persistently raised blood pressure of 170/100. Mr Smith reports no significant past medical history and denies any medication.
- The investigation of dementia in Down's Syndrome
You are asked to assess a 54 year old man with Down's Syndrome who was admitted to the medical ward following an apparent seizure two days ago. He was witnessed by a carer to be trembling uncontrollably and was unresponsive to commands. He has recently been forgetful and has lost interest in his chosen evening activity of washing-up. He sometimes fails to recognize his older sister when she visits the care home where he has stayed since his mother died 25 years ago.
- Management of osteoporosis
Osteoporosis is a common disorder with high morbidity and mortality. It is clinically silent until the first fracture. Treatment is often started late and then inadequately reviewed. Foundation doctors will find this article helpful when managing elderly patients presenting with fractures and falls and when making decisions about primary prevention in General Practice.
- Antibiotics and bowel preparation in colorectal surgery
You are asked to see a 68-year-old gentleman with a history of an episode of heavy fresh bleeding per rectum and change in bowel habit to constipation. He is on aspirin and clopidogrel following his coronary stenting a year ago. He is also known to have diabetes mellitus type 2 on metformin and gliclazide. He is apyrexial; pulse rate is 96/minute and blood pressure is 124/71. There is mild tenderness in the left iliac fossa. Digital rectal examination and rigid sigmoidoscopy had revealed altered blood in the rectum. You note that his recent haemoglobin is 7.2 g/dl; white cell count is 13.2 and INR is 1.2.
- Surgical management of transient ischaemic attack
A 73 year old female hypertensive, non diabetic ex-smoker presented to her GP with a history of sudden inability to drive eight days previously. This episode was short lived, resolving after a few hours but there were still some residual problems with coordination whilst conducting activities of daily living.
- Right hepatectomy
A 70 year old female patient with a past surgical history of a right hemicolectomy three years earlier for a caecal adenocarcinoma Dukes' B (PT2, N1, M0), who was under 6-monthly follow up in the oncology clinic with an annual surveillance computed tomography (CT) scan was found to have a new lesion in the right lobe of the liver. She was symptom free at the time of presentation.
- Thyrotoxicosis factitia
A 34 year old lady who had been treated for thyrotoxicosis for the past 18 months was admitted to hospital by an endocrinologist. After discharge he found her thyrotoxicosis frequently refractory to medical treatment. He recruited assistance from the patient’s general practitioner (GP) to ensure she was compliant with her medications and also a surgeon as it seemed likely that a thyroidectomy would be the only effective solution. After some months endeavoring to make her biochemically euthyroid, he eventually succeeded and she underwent a total thyroidectomy. However, the histology from the excised gland and the post-operative picture did not augur well with aggressive thyrotoxicosis. This case based discussion pontificates a clinical scenario that is inherently difficult to diagnose and may lead to inappropriate treatment.
- Right upper quadrant pain
Emergency surgical admissions are some of the sickest patients in the hospital and it is important that at their initial assessment appropriate management is instigated. Senior clinicians reviewing such cases will recognize the pattern of presenting history and clinical signs allowing a diagnosis to be made based on experience. We highlight an example of a case from our experience which illustrates a pitfall for the unwary that recurrently presents in surgical practice. This case based discussion highlights an atypical presentation that the inexperienced should be reminded of each time a patient is referred to them with right upper quadrant pain. We discuss the learning points from this case and suggest further reading for interested trainees.
- Pancreatico-duodenectomy
Pancreatico-duodenectomy is a common surgical procedure performed in specialist hepato-biliary units. The aim of the article is to highlight the pre-, peri- and post-operative work up and care of surgical patients presenting with lesions in the head of the pancreas and peri-ampullary region requiring surgical resection. The focus is to assist foundation doctors to appreciate specific aspects of patient-care pertinent to this type of specialist surgery.
- Pathological fractures: investigating unknown primary tumours
A 60-year-old man had noticed some mild pain and localised swelling around his left hip for 3 months. He had been losing some weight and was a lifelong smoker. One morning, he stood up from a chair and heard a loud crack from his left hip. He was in immediate pain and was unable to mobilise. An ambulance brought him to hospital where an X-ray was taken (see Figure 1). A subsequent scan performed is shown in Figure 2.
- Management of acute pancreatitis
Acute pancreatitis (AP) is an inflammatory condition of the pancreatic gland whereby pancreatic enzymes autodigest the pancreas. Although the exact mechanisms by which this process occurs is unknown, the presence of gallstones and excessive alcohol consumption are responsible for approximately 75% of attacks in the UK. Individuals typically present with acute epigastric pain that radiates through to the back, nausea and vomiting are also prominent features. The diagnosis is confirmed by a raised serum amylase, however, if individuals present more than 3 days after the onset of pain, the amylase may be normal and serum lipase measurements may be more useful. The majority of people will have mild self-limiting disease that requires supportive care only. However, of those with AP approximately 20% go on to have a severe attack characterised by the systemic inflammatory response syndrome (SIRS), and multi-organ dysfunction (MOD). Identifying early those who are likely to have a severe attack has been the driving force behind the development of scoring systems aimed to predict early those who will develop a serious attack. Those with both local and systemic complications will need to receive their care in a high dependency or intensive care unit environment and ideally be managed by multidisciplinary teams. Mortality from AP has a bimodal distribution with approximately half of the deaths occurring in the first 14 days from SIRS and MOD, which fails to respond to treatment. The second peak occurs at 3 months with MOD secondary to sepsis from infected pancreatic necrosis.
- Arterial blood gases in surgical patients
This article aims to give you more experience at interpreting arterial blood gases (ABG), with focus on situations you may find in surgical patients. You should, by now, know the methodology of how to interpret an ABG and so these questions will ask you to identify the type of acid-base disturbance; the likely diagnosis; and then the first steps of management that you should take. When reading the situation, begin to predict what type of acid-base disturbances the patient may be suffering from. The clues are there and you should be doing this as you assess real patients too.
- Post-operative complications
Worldwide it is estimated that approximately 200 to 250 million surgical procedures are performed each year. Many of these patients will suffer from one or more post-operative complications. Definitions of what constitutes a post-operative complication vary but the term generally suggests an adverse occurrence affecting a patient's well-being, which may at the very least delay recovery and in the worst cases result in lasting disability or death. Because of the difficulties in both defining post-operative complications and in gathering data, it is difficult to provide an accurate incidence of their occurrence but some studies have suggested figures as high as 30% or more. Post-operative complications may arise as a direct consequence of the surgical procedure or anaesthesia, or be related to underlying medical conditions and while not all will be serious or life-threatening even those which are mild and self-limiting may, nonetheless, be distressing to patients and since they may require treatment and prolong hospital stay, they may have significant cost implications.
- Alvarado Score For Predicting Acute Appendicitis
Acute appendicitis is a common surgical emergency and junior doctors with limited surgical experience are often first to assess patients with possible appendicitis. A diagnostic delay increases the risk of perforation, post-operative complications and longer hospitalization periods. Prompt surgical assessment and diagnosis is therefore crucial to prevent complications and reduce morbidity. The Alvarado scoring system enables risk stratification of suspected appendicitis cases and is a useful diagnostic tool that can be implemented by the foundation year doctor. The aim of this article is to provide junior doctors with knowledge of the Alvarado scoring system including its efficacy and limitations.
- Managing The Acute Abdomen
A patient presents to A&E twice in one week complaining of central abdominal pain. After re-presenting to A&E she was admitted under the gynaecology team where she went on to develop four quadrant peritonitis and underwent an emergency laparotomy. Was something missed on her first presentation?
- Acute Bowel Ischaemia
Acute bowel ischaemia is a common and potentially life threatening condition encountered by the junior doctor on the acute surgical take. We discuss the presentation, aetiology and appropriate treatment for this surgical emergency. The junior doctor should be aware of the required investigations and initial management for patients with suspected acute bowel ischaemia and understand the need to quickly escalate to more senior members of the team.
- Ischaemic Colitis & Bleeding per Rectum - A Surgical Emergency
Gastrointestinal bleeding (GI) is a common emergency presentation to hospitals. It accounts for about 1% to 2% of all emergency admissions. It is classified into upper and lower GI bleeding and the ligament of Treitz is traditionally considered the dividing point between the two. Any bleeding distal to its insertion (Duodeno-Jejunal flexure) is considered lower GI bleeding. Presenting history plays an important part in diagnosis and treatment plan. The authors present a 63 years old male patient with lower GI bleeding and abdominal pain due to ischaemic colitis. The article discusses the causes, investigation and management of lower GI bleed with focus on ischaemic colitis.
- Ureteric complications after renal transplant
Kidney transplant is the best available treatment option for most patients with end-stage renal failure. Although relatively uncommon, complications affecting the ureter of the transplant kidney can cause significant morbidity. Here we discuss two cases that illustrate typical ureteric complications associated with renal transplantation.
- Surgical complications related to IV drugs abuse
Injection drug users (IDUs) not uncommonly present to the emergency department (ED) with cutaneous and vascular complications (1). Although numbers injecting (cocaine and heroine) have fallen (93,401 in 2010-11, 87,302 in 2011-12) (2), hospital admissions due to injection site complications have increased (3). These complications include localised cellulitis, abscess development, pseudoaneurysm (PA) formation, compartment syndrome and necrotising fasciitis (NF) (4). The following case-based discussion exemplifies how a typical intravenous drug user may present; we discuss the important differentials and the challenges faced in managing these complications.
- Necrotising fasciitis
Necrotising fasciitis is a life-threatening soft tissue infection that can be a diagnostic challenge due to a lack of specific signs. An awareness of the clinical features and diagnosis are vital for foundation doctors who are often the first doctor to assess patients being admitted to hospital. Early diagnosis through having a high index of suspicion and early surgical debridement of necrotic tissues are key and can be life saving. This case based discussion will highlight these aspects in detail to give the reader more confidence in managing these uncommon but difficult cases.
- Acute pancreatits: a review for the foundation doctor
Acute pancreatitis commonly presents on the acute surgical take with an incidence of 56.5/100,000 people in the UK, and a predicted mortality of 5% (1). Effective assessment and early management of patients with pancreatitis is crucial to prevent complications and prolonged hospital admission. This paper focuses on the assessment and management of acute pancreatitis derived from current evidence-based guidelines. We will highlight pertinent aspects of the history and examination, aetiological factors, investigations and scoring systems and finally critical aspects of early management that will aid in improving morbidity and mortality.
- Management of a patient with not so "mild" acute pancreatitis
We present the management of a 73 year old lady with acute pancreatitis (AP). She was initially predicted as having mild AP with a Glasgow score of 1 and treated with analgesia and intravenous fluids before being discharged after 7 days. She was readmitted 4 days later and diagnosed with necrotizing pancreatitis on CT scan. Antibiotics were started and 4 days later she was discharged home. She was readmitted 6 days later septic and a repeat CT scan showed infected walled off necrosis. This was treated with a cyst-gastrostomy, debridement of necrotic tissue and cholecystectomy. She made an uneventful recovery and was discharged after 9 days. An out-patient MRCP was normal. The cause of her AP was likely to be due to gallstones but this was not proven. We discuss the importance of measuring serum amylase, severity scoring systems, the accuracy of ultrasound, and the role antibiotics.
- Surgery in the Jehovah's Witness
In this article, we have considered the Jehovah's Witness (JW) undergoing surgery. The pre-operative considerations, blood conservation techniques and post-operative care are discussed.
- A traumatic C-Spine injury with extensive head wound
Patients with traumatic head injuries can be daunting to manage, especially in the middle of the night. It is imperative to approach the patient as per Advanced Trauma Life Support (ATLS) guidance and get senior assistance early. Closure of scalp wounds requires adequate time, appropriate analgesia, consent and knowledge of the difference techniques for wound closure and complications that can develop. I present a case of a 75 year old female who attended A&E in the middle of the night after a mechanical fall with an unstable, c-spine injury and a deep laceration to her scalp of unknown size or depth. I present the step – by – step process of this lady’s scalp wound closure with the issues raised, followed by MCQs.
- The differentials of right upper quadrant pain and the peril of diagnostic anchoring
Emergency surgical admissions are some of the sickest patients in the hospital and it is important that at their initial assessment appropriate management is instigated. Senior clinicians reviewing such cases will recognize the pattern of presenting history and clinical signs which allows them to make a diagnosis based on their experience. Unfortunately mistakes are made and we highlight a case from our experience that recurrently presents in surgical practice. The following discussion highlights an atypical presentation that junior doctors should be reminded of each time a patient is referred to them with right upper quadrant pain. We discuss the learning points from this case and suggest further reading for interested trainees.
- Patient suffered a traumatic C-spine injury with extensive head wound
Patients with traumatic head injuries can be daunting to manage, especially in the middle of the night. It is imperative to approach the patient as per Advanced Trauma Life Support (ATLS) guidance and get senior assistance early. Closure of scalp wounds requires adequate time, appropriate analgesia, consent and knowledge of the difference techniques for wound closure and complications that can develop. I present a case of a 75 year old female who attended A&E in the middle of the night after a mechanical fall with an unstable, c-spine injury and a deep laceration to her scalp of unknown size or depth. I present the step–by–step process of this lady's scalp wound closure with the issues raised, followed by MCQs.
- Adrenal masses: management of adrenal adenoma
Most adrenal masses are found incidentally during cross-sectional imaging. The investigations and management of an adrenal mass requires a thorough understanding of adrenal pathophysiology. We highlight the diagnosis and management of adrenal adenomas.
- Adrenal Masses: The Management of Adrenal Metastatic Tumour
The adrenal gland is a common site for metastasis from a variety of malignancies. We present a patient with a solitary adrenal metastatic tumour originating from a primary tracheal sqaumous carcinoma. This case based discussion focuses on the assessment and management of metastatic adrenal disease.
- Adrenal Masses: The Diagnosis and Management of Cushing's Disease
The diagnosis of Cushing's syndrome is often missed due to its subtle clinical signs and symptoms. This case highlights the diagnosis of Cushing's syndrome focusing on the management and treatment of pituitary-dependent Cushing's disease.
- Adrenal Masses: The Diagnosis and Management of Conn's Syndrome
This case highlights the clinical history and presentation of a young man with hyperaldosteronism. We discuss in detail the aetiology, investigations and treatment options of patients with Conn's syndrome.
- Adrenal Masses: The Diagnosis and Management of Phaeochromocytoma
We discuss a case of a patient with bilateral phaeochromocytomas. This case highlights general aspects of the diagnosis, management and treatment of a phaeochromocytoma, a relatively rare adrenal lesion.
- The surgical management of bowel cancer
Management of bowel obstruction secondary to cancer can be challenging. A patient with an obstructing bowel cancer is presented in detail. This patient's management is used to illustrate management of a complex obstructing bowel cancer. Aspects discussed include aims of treatment, assessment of disease and choice of appropriate surgical management.
- Adrenal masses: The diagnosis and management of phaeochromocytomas
We discuss a case of a patient with bilateral phaeochromocytomas. This case highlights general aspects of the diagnosis, management and treatment of a phaeochromocytoma, a relatively rare adrenal lesion.
- Adrenal masses: the management of adrenal adenoma
Most adrenal masses are found incidentally during cross-sectional imaging. The investigations and management of an adrenal mass requires a thorough understanding of adrenal pathophysiology. We highlight the diagnosis and management of adrenal adenomas.
- Assessment of leg weakness in the older patient
You are assessing a 84–year-old gentleman who presented with a 3-month history of confusion and progressive weakness and paraesthesia in his lower legs. He has been treated with a course of antibiotics for a lower respiratory tract infection but he has continued to worsen despite this. He has a history of type 2 diabetes, ischaemic heart disease and hypertension. His medications are as follows: - Aspirin 75mg od - Bendroflumethiazide 2.5mg od - Simvastatin 40mg od - Ramipril 5mg od - Amitryptilline 10mg od - Multivitamins
- Management of the older patient attending hospital with a fall
Mrs. Turner is an 82-year-old woman who has been brought in by ambulance to the Emergency Department of her local district general hospital, accompanied by her daughter. Her daughter called by in the morning as planned and, having let herself in when there was no answer to the doorbell, found her lying on the landing outside her bedroom. The ambulance crew report that she had been incontinent of urine. Her GCS was noted to be 15/15. She complained of pain in the upper thigh but denied any head or neck injury. On arrival in the MAU she had her baseline observations recorded by nursing staff: she is alert, her pulse is 55 bpm, BP 140/85, respiratory rate 16, oxygen saturation 99%, temperature 37.8°C. A urine dipstick shows leukocytes , ketones but is otherwise clear. X-rays ordered by the Emergency Department staff showed a left pubic ramus fracture, but the hips were OK. Analgesia was given promptly
- Palpitations or panic attack?
A 72-year-old lady was seen by her general practitioner and attended her local emergency department on several occasions over a 9-month period with episodic symptoms. She had attended the emergency department three times in the preceding 5 days. Her symptoms consisted of palpitations, light headedness, chest tightness and shortness of breath. The palpitations were of rapid onset and offset and consisted of a sensation of a rapid regular heart beat. She had been previously diagnosed as having an anxiety disorder, and the episodes attributed to panic attacks (1). She was otherwise in general health.
- Transient ischaemic attack (TIA)
A 78-year-old man attends the medical admissions unit via his GP. Yesterday he noticed weakness and clumsiness of his right hand with slurred speech lasting for 50 minutes. This did not concern him and he had only mentioned it to his GP during a routine check-up. He tells you that he feels fine and doesn’t understand “what all the fuss is aboutâ€. His previous medical history includes type 2 diabetes and hypertension. He takes amlodipine 5mg od, ramipril 10mg od on repeat prescription.
- Management of acute stroke
An 80-year-old woman was found lying on the floor by her daughter and when the paramedics arrived, her eyes were deviated to the left, she had a right-sided hemiparesis, with a Medical Research Council (MRC) grade 1/5 weakness of the upper and lower limb and she was aphasic. There was no evidence of head injury. She was in sinus rhythm with a rate of 80 beats per minute, blood pressure of 170/100mmHg and capillary glucose of 5.7mmol/L. There were no bruits or murmurs audible on examination and she had no abnormalities on respiratory or abdominal examination. You are called to assess the patient in the emergency department.
- Parkinson's disease
A 72 year old man attends a general medical clinic with his son. The father has been referred by his General Practitioner with “General Declineâ€. As the Foundation Year 2 doctor you are asked by your consultant to assess him. You notice that it takes him several minutes to enter the consultation room, and whilst going to assist him you observe a slight shake in his right hand. He has a soft voice, and frequently dabs at the corner of his mouth with a tissue. During the course of the consultation it is apparent that his most troubling symptoms are falls, difficulty being heard and hyper-salivation which he finds embarrassing. You comment on his tremor and his son mentions that they have been concerned about the possibility of Parkinson’s disease.
- Osteoporosis, fractures & bisphosphonates
Ms MA presented with bilateral, sequential bisphosphonate-related subtrochanteric fractures. Unique clinical and radiographic features surrounding these atypical fractures that have been illustrated in the literature are identified in this case.
- Psoas abscess secondary to osteoporotic vertebral fracture
Psoas abscess is rare in elderly people and often presents with vague clinical findings. A high index of clinical suspicion is required for the diagnosis. This case emphasizes the importance of bacteriological confirmation of microorganism in order to raise suspicion of disease and establishing the appropriate investigation and treatment early in the disease process.
- A mediastinal abscess developing secondary to a gangrenous diabetic toe
Acute mediastinitis and abscess formation in the anterior mediastinum is rare and carries a high mortality if diagnosed late. A 79 year old gentleman presented with left sided shoulder pain. His past medical history included ischaemic heart disease, type 2 diabetes, and a recent admission for an infected gangrenous diabetic toe. He was found to have a 10cm mass in his left anterior chest wall on computed tomography (CT) imaging. Ultrasound confirmed this to be an abscess. The patient deteriorated and died before the abscess could be drained. A postmortem confirmed a Staphylococcus aureus anterior mediastinal abscess, and signs of sepsis likely to have developed secondary to haematogenous spread from the infected gangrenous toe. The case highlights the high mortality of this condition and therefore the need for a high index of suspicion, as early diagnosis and treatment are essential.
- Rigid sigmoidoscopy and flatus tube insertion for sigmoid volvulus
Sigmoid volvulus is a common cause of large bowel obstruction in the elderly and in many cases it can be recurrent. If promptly diagnosed, it can be safely treated by performing a rigid sigmoidoscopy and then inserting a flatus tube. Very often, this would provide almost instant relief for the patient. After reading this article, the reader would have a good understanding of how to perform a rigid sigmoidoscopy and insert a flatus tube. They would also have an understanding of the various indications and contra-indications for this procedure.
- Polymyalgia rheumatica
This article looks at the presentation, investigation and appropriate management of Polymyalgia Rheumatica (PMR). This is the most common inflammatory rheumatic condition in the elderly. There is a wide differential diagnosis. Investigations to help make the diagnosis and regular assessment of the clinical course must be made to ensure successful treatment. The aim of this article is to illustrate, through the use of a case, the important aspects of the history, examination, investigation and treatments for a patient presenting with PMR.
- Infective endocarditis in an older person
An 82-year-old man was admitted to hospital having fallen at home. His son found him on the floor and the fall was not witnessed. He was pyrexial, acutely confused and unable to give a history. It was unclear how long he had been lying on the floor and what had lead to his collapse.
- Diagnosing dementia in primary care
Dementia represents a big diagnostic challenge for primary care health professionals as it is often insidious in onset and can present with varied symptoms and signs. The cost of care for people with dementia in the UK is greater than the combined annual expenditure on heart disease, stroke and cancer, combined. An early diagnosis of dementia is crucial as this enables patients and their families to seek early and appropriate support from medical and psycho-social services, significantly improving morale and delaying the need for 24 hour care (1).
- A totally reversible cause of mobility loss in an elderly patient
An 80-year-old man presented with an 8-weeks history of progressive lower limbs weakness of lower motor neuron-type, rendering him unable to weight bear. There was no history of back pain or trauma, and he denied bladder or bowel problems. Investigations including blood tests and MRI of the spine were normal, while CSF examination revealed increased protein level. Nerve conduction studies showed evidence of proximal conduction block, suggestive of inflammatory demeylination. Our patient responded well to immune suppression with intravenous immunoglobulin and oral steroids. He became mobile with a rolator within 2 weeks and independently mobile after 4 weeks of starting treatment. The clinical diagnosis was chronic inflammatory demyelinating polyneuropathy (CIDP). CIDP can be thought of as a subacute or chronic onset Guillan–Barré syndrome (GBS). CIDP is probably under diagnosed in the elderly. It needs to be considered in all elderly patients with progressive loss of mobility.
- End-stage respiratory disease: managing distressing symptoms
Respiratory disease is a major cause of mortality in the UK. The symptom burden is often underestimated and is comparable to the symptoms of malignant disease. End stage respiratory disease is often marked by a slow, relentless decline with prolonged periods of disability secondary to dyspnoea, reduced exercise tolerance and multiple hospital admissions. The main symptom encountered is breathlessness which can be challenging to manage. The following article describes the issues faced by a patient suffering from end stage chronic obstructive pulmonary disease and offers guidance for the management of distressing symptoms.
- Food and fluid at the end of life
In some patients, artificial nutrition and hydration (ANH) can improve general well-being and prolong life (1). However, in patients with a life-limiting illness, ANH could potentially prolong suffering. In dying patients, the burden of ANH can often outweigh any medical benefits. This article uses a case to illustrate some of the clinical considerations around ANH at the end of life and reviews the available evidence. In the context of this article "end of life" refers to the last days of life.
- The management of malignant pleural effusions
This article examines the assessment and management strategy of patients with a malignant pleural effusion with the aid of an illustrative case history.
- Care of the dying patient in hospital
Around half a million people die in England each year and 58% of these deaths occur in the hospital setting. Almost two-thirds of these deaths occur in people aged over 75 and follow a period of chronic illness, e.g. heart disease, cancer, stroke, chronic respiratory disease and dementia (1). However, despite the large number of dying patients that we care for in hospital, evidence suggests that we provide suboptimal care (2,3). This is also reflected by the high number of complaints received by the Healthcare Commission involving issues around death4. Over the last two decades, the relatively new speciality of Palliative Care has emerged with the aim of providing advice and guidance on the medical management of symptoms at the end of life closely linked to a much more holistic approach of providing emotional, social and spiritual support for patients and their carers. The important role of palliative care is also covered in the undergraduate and Foundation programme curricula (in particular, communication skills, breaking bad news, and skills and knowledge supporting DNAR orders and advance directives).
- Vaccinations in the elderly
This case report reviews the role of vaccination in protecting the elderly, who are at particular risk from infections including influenza and pneumonia and their associated complications. The availability, indication and context of appropriate vaccination are discussed.
- Detrusor instability
This case based discussion focuses on an independent, community-dwelling 84-year-old lady presenting with urinary incontinence and discusses the assessment, differential diagnosis and treatment of urge incontinence due to detrusor instability.
- Rehabilitation in a cognitively impaired patient
Mrs EW, an 84-year-old woman, was admitted to the Emergency Department after being found on the floor by her home help. The patient had a past history of dementia and was at risk of falls. After initial management and investigation for possible causes of falls the patient wanted to go home. There were concerns raised about her safety by her daughter who wanted her mother to be admitted to a residential home. The focus of this case based discussion is on rehabilitation in patients with cognitive impairment and discharge planning.
- Vaginal discharge
Infection is the most common cause of pathological vaginal discharge. The most common infections are bacterial vaginosis (BV) and candidiasis. Sexually transmitted diseases that may present with vaginal discharge include trichomoniasis, chlamydia and gonorrhoea. Because of the long-term morbidity and public health implications of these infections they should always be considered in women at risk of sexually transmitted diseases. Microscopy and culture of vaginal and endocervical swabs are the mainstay of investigation of vaginal discharge, but for some infections they are increasingly being superseded by nucleic acid amplification techniques. In this article the various infective causes of vaginal discharge, and their treatment, are discussed and recommendations for selection of appropriate microbiological investigations according to the clinical presentation are proposed.
- Acute pelvic inflammatory disease
A 19-year-old woman presented to Accident and Emergency with a history of worsening lower abdominal pain of 5 days duration. This was associated with an abnormal vaginal discharge. On examination, she was febrile with a tender abdomen and cervical excitation. High vaginal and endocervical swabs were taken. A pregnancy test was negative. A transvaginal ultrasound scan revealed an adnexal mass. At laparoscopy, access was difficult due to adhesions. Hence laprotomy was performed with drainage of pelvic abscess and adhesiolysis.
- Lower abdominal pain in women of child-bearing age
A 29-year-old woman attends the emergency department with a 1-day history of cramping lower abdominal pain, associated with nausea. She has no associated urinary or bowel symptoms. On examination, she is anxious and in pain, with a visual analogue score of 6/10. Apart from a heart rate of 100 beats per minute, her vital signs are within normal limits. Her abdomen is soft, with tenderness in the right lower quadrant. On venous blood testing, her white cell count is 12,000/µL. A urine dipstick confirms pyuria (leucocytes 2 ), with negative nitrites. The urine pregnancy test is negative. How would you proceed to manage her?
- Acute lymphoblast leukaemia
A 23-year-old medical student attended his General Practitioner (GP) with fl-like symptoms and a headache. On further questioning he admitted to feeling very tired recently and also commented that he had some lost appetite and had lost weight over the previous few weeks. He also reported feeling rather more unwell over the last 24 hours with a frontal headache and dyspnoea. He had no significant past medical history and was not on any regular medications. He had two brothers and one sister who were all well. A full blood count and infectious mononucleosis screen were requested.
- A case of hypercalcaemia
A previously fit 29-year-old Ethiopian woman who had been living in the UK for several years presented to casualty with a two month history of back and epigastric pain, weight loss, sweats and constipation. She had received ibuprofen and antibiotics from her GP to no effect. She did not smoke or take alcohol. There was no previous history of TB or contact with it. There was a family history of diabetes and hypertension. She had two male siblings.
- Prescribing warfarin: everything you need to know
A 74-year-old retired builder presents to the medical assessment unit with a 2-day history of tiredness, weakness and dark stool. There is no history of weight loss, anorexia, dysphagia or change in bowel habit. Signifiant past medical history includes atrial fibrillation, for which he is receiving warfarin, and gastro-oesophageal reflex disease (GORD) but no previous history of peptic ulceration. Over the last 5 days he had also been receiving ciproflxacin for a presumed urinary tract infection (UTI). Examination demonstrates conjunctival pallor and melaena. Initial investigations reveal an Hb of 8.5 and an INR of 6.9. LFTs are normal.
- Low vitamin B12
One of your patients has had their blood test results which show a low Vitamin B12 level. What does that mean?
- Hypercalcaemia
An 84-year-old lady was admitted to hospital by her GP with nausea, constipation and confusion. Five days previously her morphine sulphate modified release tablets prescribed for pain had been increased from 40 mg twice a day to 80 mg twice a day. The staff at the residential home she lived in were not sure if this coincided with the onset of confusion. The patient had a background of breast cancer, which she did not think had spread anywhere else.
- The Use of heparins for the treatment of pulmonary embolism
Mrs VT has been brought in to A&E by ambulance following collapse after sudden onset of shortness of breath and chest pain. She has a past medical history of COPD. She is found to be tachycardic, hypotensive and peripherally shut down. Her left leg is signifiantly swollen. A 12 lead ECG reveals a sinus tachycardia with t-wave inversion in the precordial leads. CXR demonstrates changes consistent with COPD only. You suspect a massive pulmonary embolism (PE) and request an urgent computed tomography pulmonary angiogram (CTPA).
- Neutropenic sepsis
The haematology ward calls you to see a 40-year-old man who called in earlier with a 3-hour history of a fever above 37.8C. He is known to have Acute Myeloid Leukemia and had chemotherapy a few days ago.
- Ruptured abdominal aneurysm
A 65-year-old retired builder was admitted to casualty following a collapse. He was tachycardic and hypotensive with an increasingly distended abdomen. He was becoming drowsier and complaining of generalised abdominal and back pain. Previously he had suffered a myocardial infarction and was diabetic. He smoked 20 cigarettes a day and was clinically obese. On examination, he was cold, clammy and distressed. His abdomen was generally tender, distended, tense and pulsatile.
- Severe hyponatraemia
A 79-year-old lady presented with a 3-day history of increasing confusion and reduced mobility. She had an episode of diarrhoea which resolved 3 days prior to admission. She had no other symptoms when seen. She was noted to be on Atenolol 25 mg/day and Bendrofluomethiazide 2.5 mg/day for hypertension, as well as aspirin 75 mg once daily, and diclofenac 75 mg twice daily.
- Assessment and management of haemoptysis
A 56-year-old man attends the emergency department following a history of intermittent haemoptysis over the preceding two weeks. This commenced with streaking of blood, and he coughed up a cupful of fresh blood on the morning of attendance. There was no history of chest pain. He has no systemic symptoms, and is otherwise in good general health. He has been a smoker from the age of 19, currently smoking 10 cigarettes a day. On examination, there are no localising signs in the chest. How would you manage him further?
- Treatment of neutropenic sepsis
This case based discussion focuses on a 34 year-old female who underwent her second cycle of chemotherapy 10 days ago and now presents with a temperature of 38.5 degrees. The case discusses the assessment, differential diagnosis and treatment of patients who present with neutropenic sepsis.
- Diffuse large B-cell lymphoma occurring in a patient with hairy cell leukemia and prostatic adenocarcinoma
A 75 year-old man with previous history (of prostatic adenocarcinoma) was referred for evaluation of pancytopenia in December 2006. A diagnosis of hairy cell leukaemia (HCL) was made. The patient was commenced 2 cloro-deoxyadenosine treatment, attaining a complete remission. Four months later he presented with inguinal & supraclavicular lymphadenopathy, and hypercalcemia. A lymph node biopsy revealed infiltration by diffuse large B cell lymphoma (DLBCL). Though HCL is associated with increase incidence of second malignancies, simultaneous occurrence of DLBCL and HCL remains an uncommon event. A literature review showed only 13 cases have been published to date. The origin and clonal relationship of heavy or light chains immunoglobulin genes in the two pathologies is also discussed.
- A case of mixed warm and cold autoimmune haemolytic anaemia
Anaemia is a common finding in patients admitted to hospital and results from either failure of red cell production, or from increased red cell destruction or loss. We present a rare case of mixed cold and warm autoimmune haemolytic anaemia. The patient's presentation, initial findings and more specialised investigations are discussed, along with management of the case and complexities of the diagnosis.
- Multiple myeloma complicated by thrombosis
Multiple Myeloma is a malignancy characterised by clonal expansion of plasma cells in the bone marrow and usually the subsequent over expression of a monoclonal immunoglobulin (M-protein) in the blood. It accounts for 1% of all malignancies and 15% of haematological malicnancies (1). The median age at diagnosis is approximately 70 years of age therefore it can be considered disease of the elderly. Myeloma is heterogeneous in its presentation, from complications due to lytic lesions and hypercalcaemia to anaemia and renal failure. Investigation of myeloma is relatively straight forward; however interpretation of immunoglobulin results as they come back is poorly understood and often proves problematic. Although Myeloma is a largely incurable cancer, with modern therapeutics the prognosis has improved significantly in the last 15 years. A typical patient with Myeloma will have multiple remissions and relapses with a new treatment for each relapses. Here I recount a case of myeloma in a typical patient; from diagnosis to current status in her disease. Discussion includes interpretation of immunoglobulin results and the initial investigations in myeloma. Her case is unusual in that she developed a thrombosis in an unusual site as a result of her treatment. The complication has an ongoing impact in her management and overall prognosis.
- A case of easy bruising
We discuss the case of a 67 year old lady who presented with spontaneous bleeding and headache. Initial blood tests demonstrated a pancytopenia and deranged clotting tests. The blood film confirmed pancytopenia and demonstrated myeloid blasts with concerning features for acute promyleocytic leukaemia (APML). An urgent CT demonstrated acute intracranial haemorrhage. She was managed with aggressive blood product support and neurosurgical intervention. She was immediately commenced on all-trans-retinoic acid and subsequently chemotherapy to treat the leukaemia. The diagnosis was subsequently confirmed on bone marrow molecular studies. She is currently in remission from her leukaemia and has no neurological sequelae. We discuss an approach to the assessment of patients with spontaneous bruising and a summary of the pathophysiology and management of patients with APML.
- Anticoagulation, adverse effects and antidotes
Warfarin has been the most commonly prescribed oral anticoagulant for many years until the recent introduction of the novel anticoagulants such as Dabigatran and Rivaroxaban. The presence of a mechanical heart valve is an indication for anticoagulation. The main side effect of warfarin is bleeding, with intracerebral haemorrhage being one of the most serious bleeding risk requiring immediate reversal management. This patient had immediate warfarin reversal but developed pulmonary emboli as a result. This case highlights the difficulties managing a patient with concurrent haemorrhage and thrombosis.
- The investigation of a bleeding patient
A case of sudden onset bruising which demonstrates the approach to a general medical patient with bruising or bleeding. This article outlines the key investigations and their interpretation, followed by the management of acquired haemophilia A.
- A case of heparin induced thrombocytopenia
This article describes a case of heparin induced thrombocytopenia (HIT) in a patient following above knee amputation for an acute ischaemic lower limb. It discusses the differential diagnoses which should be considered in surgical patients with thrombocytopenia, who is at risk of heparin induced thrombocytopenia, when a diagnosis of HIT should be clinically suspected and briefly how HIT is diagnosed and managed.
- Investigating raised serum ferritin
This report describes the case of a 59 year old Scottish Caucasian woman with a history of alcohol excess and bipolar disorder was referred to the Haematology clinic after investigations revealed a serum ferritin (SF) level of 5346 ug/l (reference range 10 - 275 ug/l). Molecular testing revealed that the patient was homozygous for the C282Y mutation, confirming the diagnosis of hereditary haemochromatosis. However, since the patient had an excessive alcohol intake, deranged LFTs, clinical features of chronic liver disease and an abnormal appearance of left lobe of the liver, alcoholic liver disease might have been accepted as the sole explanation for her hyperferritinaemia. This case demonstrates the challenge of differentiating causes of hyperferritinaemia, especially in patients in whom more than one potential explanation exists. Investigations which may help in this regard are discussed as a prompt to Foundation Year trainees who may be consulted by such patients who may present to haematology, rheumatology or gastroenterology.
- The spectrum of complications in myeloma
Myeloma is a plasma cell neoplasm accounting for 10-15% of all haematological malignancies (1, 2). A disease of the elderly, the median age at presentation is 65 (1). Plasma cells are derived from B-lymphocytes whose usual role is to produce immunoglobulins (antibodies). In myeloma a genetic insult results in development of a malignant plasma cell clone in the bone marrow with impaired production of normal blood cells. Characteristically a monoclonal immunoglobulin known as a paraprotein is produced (1,2), which aids diagnosis and monitoring response to treatment. Sometimes only immunoglobulin light chains are produced. These are detectable in urine as Bence-Jones protein and blood as serum free light chains (3). Myeloma is almost always preceded by a pre-malignant state called monoclonal gammopathy of unknown significance (MGUS), although this often goes unnoticed due to the absence of symptoms (3). The risk of progression from MGUS to myeloma is low at around 1% per annum. This article will focus on Ms J, a 56 year old lady, who presented with a very aggressive form of myeloma. Acute management of myeloma complications will be discussed with a particular emphasis on sepsis and renal failure.
- Cautions and hazards of blood transfusion: a case of hyperviscosity syndrome
Transfusion of blood products can be life saving in certain scenarios but careful assessment should be carried out to balance the risks and benefits. We explore situations where transfusion of red cells could potentially increase the risk of complications and give as example, a patient with severe anaemia and hyperviscosity syndrome. This article also addresses the management of acute transfusion reactions, a common scenario that junior doctors will have to tackle in their daily practice.
- Hodgkin lymphoma presenting with superior vena cava obstruction (SVCO)
This case based discussion focuses on a 17 year old female who presented with dyspnoea as a consequence of superior vein cava obstruction (SVCO). The case explores the presentation, investigations and management of SVCO in a patient with previously undiagnosed Hodgkin lymphoma.
- Pancytopenia: a case of hairy cell leukaemia
Pancytopenia is a common presentation to our day-to-day clinical practice. The causes of pancytopenia are diverse and severe pancytopenia can be life threatening therefore warrant urgent assessment and treatment. In this article, we described a case of pancytopenia caused by a rare form of leukaemia, hairy cell leukaemia, and illustrated a step-to-step approach leading to the diagnosis.
- Hyperviscosity syndrome in a patient with underlying Waldenström's Macroglobulinaemia
This case based discussion focuses on a 79 year old male with hyperviscosity syndrome found to have an underlying Waldenström's Macroglobulinaemia. This case explores the presentation, investigations and treatment of hyperviscosity syndrome.
- Acute kidney injury (AKI) - diagnosis, investigation and management
Around 20% of hospitalised patients develop AKI (1). The NCEPOD (National Confidential Enquiry into Patient Outcome and Death) review of patients who died in hospital with AKI reported that only around 50% of patients received (what they determined as) good AKI management (2). It is vital to understand how to diagnose, investigate and manage AKI appropriately in order to lessen the high morbidity and mortality associated with this condition.
- Infections in renal transplantation
A 48 year old gentleman with adult polycystic kidney disease received a deceased donor renal transplant. His maintenance immunosuppressive therapy was tacrolimus and mycophenolate mofetil. He presented 8 months post-transplantation with fever and profuse diarrhoea for the previous 5 days (no blood), abdominal pain and lethargy. Initial investigations demonstrated an acute increase in serum creatinine from his baseline, together with a low white cell count and platelets. Here we discuss common infections in renal transplantation patients.
- Renal disease in myeloma
Myeloma is the second commonest haematological malignancy and is often complicated by renal involvement. We present a case of renal disease in myeloma, and describe the principles behind investigation and management.
- Nephrotic syndrome diagnosis & managment
The term “dropsy†has been known about since ancient times and means oedema. Nephrotic syndrome has been described by various eminent scientists through the ages as either the result of excessive loss of protein from the kidney or excessive salt and water accumulation due to the chronic states of heart failure and liver cirrhosis. The most notable consequence of continued proteinuria is expansion of body water leading to oedema.
- Severe Combined Immune Deficiency (SCID)
Severe Combined immunodeficiency syndrome (SCID) is a rare and serious type of inherited immune deficiency resulting in poor function of the immune system. A SCID diagnosis is a medical emergency which requires early treatment. This article aims to increase awareness, enabling early diagnosis and specialist referral for potentially lifesaving treatment.
- Angioedema - case-based discussion
Recurrent angioedema, due to oedema of subcutaneous tissue, may present to primary or secondary care. Laryngeal angioedema can be life-threatening. Causes include idiopathic or spontaneous angioedema (with or without urticaria), drugs including angiotensin converting enzyme inhibitors (ACE-I), allergy, and rarely C1 inhibitor deficiency. Salient features in the history can help to determine aetiology facilitating appropriate treatment.
- Anaphylaxis and venom immunotherapy
We describe the case of a patient who had an anaphylactic reaction to a wasp sting and elicit the typical features of anaphylaxis. We go onto discuss the underlying immunology looking specifically at the role of IgE. We review appropriate emergency management, and subsequent investigation of anaphylaxis. Finally, the role of venom immunotherapy is explored.
- Important AIDS-defining illnesses in the UK
This article aims to discuss important AIDS-defining illnesses in the UK pertaining to all doctors to improve detection of HIV, as earlier detection confers a more favourable prognosis.
- Infective endocarditis: how immunology tests may help or mislead
Immunopathology plays an important role in infective endocarditis. In this context, two cases are presented here. In both patients, several abnormal immunological test results were obtained. Some findings were typical, whereas others were unanticipated and potentially misleading. Failure to interpret such findings correctly could lead to selection of inappropriate and potentially highly dangerous treatment. Pitfalls associated with immunological testing in this model of chronic infection are discussed. The need for clinicopathological liaison in the interpretation of diagnostic results is emphasized.
- Immunosuppression in renal transplantation
Kidney transplant is the best available treatment for end-stage renal disease. It leads to improved quality of life, prolonged survival and is cost effective compared to dialysis. Despite the above advantages it is related to significant morbidity and mortality due to opportunistic infection and other complications as a consequence of immunosuppression. Here we discuss three renal transplant cases that illustrate some of these complications.
- Treatment of anaphylaxis
You are called to see a 28-year-old man on the medical admissions unit. He is a type 1 diabetic in hospital with a community acquired pneumonia. The nurse tells you that he is looking increasingly unwell and has just been given IV amoxicillin as treatment for the pneumonia. He is not known to have any drug allergies but has not had amoxicillin before. You advise that the antibiotics are stopped immediately and you assess Mr D. On arrival, Mr D does not look well – he is having difficulty speaking to you and appears slightly confused. His respiratory rate is 25 breaths/minute and oxygen saturations are 85% on air. Examination of his chest demonstrates a marked wheeze throughout. Further examination shows him to have cool peripheries and you record a blood pressure of 80/55 and feel a weak, thready pulse, rate 124bpm. His capillary refill time is 3 seconds and he is becoming increasingly drowsy during your assessment. You suspect a diagnosis of anaphylaxis to the IV amoxicillin. How should you manage this patient?
- Urticaria and angiodema
Urticaria describes short-lived slightly raised, itchy red patches anywhere on the body. Angioedema describes swelling occurring slightly deeper in the skin and mucous membranes. Urticaria may affect more than 20–25% of the population at some point in their lives. Most patients suffer both urticaria and angioedema although one may predominate in some patients. Urticarial patches are often pale in the centre and vary between a few millimetres across to 10cm or more across. These patches can sometimes become confluent giving the impression of diffusely swollen, itchy red skin. They can affect any area of the body and usually last from 30 minutes to as long as 48 hours or more. Apart from the discomfort of the itching, systemic symptoms are usually absent in simple urticaria and angioedema. Some patients may feel tired. When the individual patches of urticaria last longer than 36 hours, or are associated with bruising, then an inflammation of cutaneous blood vessels should be suspected as part of a cutaneous vasculitis. The latter is often associated with arthralgia, myalgia and mild fever.
- A febrile and confused patient
The confused and febrile patient is a staple of acute medical takes. The differential is often wide, ranging from the common but relatively trivial to the rare but life-threatening. Below we present a typical case, discuss the causes not to miss, how to recognise these patients and how to ensure that they are managed optimally.
- Pyrexia of unknown origin
We present a case of a 30-year-old German student who was admitted with persistent fever, weight loss, joint pains and headache. She was originally referred for an oncology opinion by her GP, who was suspicious of an underlying haematological malignancy. She complained of 3-months intermittent fever, night sweats, fatigue and approximately 4kg weight loss. A rash had developed on her lower limbs and she described poorly localised abdominal pain, together with joint pains in her hands, feet and knees. In addition, she reported episodes of severe headache that resolved spontaneously. She had a past history of vitiligo with no significant family history. She took no regular medications, had no allergies, did not smoke and reported minimal alcohol intake. She was not sexually active and had no other risk factors for HIV infection. She had spent 6-months working as an anthropologist in West Africa in 2006. On examination her temperature was 38.0 and she looked comfortable. She was pale with a diffuse petechial rash affecting both her lower limbs. Her spleen was palpable 2 fingerbreadths below the costal margin. Joint examination was unremarkable. General physical examination was otherwise normal.
- An interesting case of brucellosis
A 32-year-old man, referred to our hospital (Royal Blackburn Hospital, Blackburn) with the complaints of fever with dry cough. His problems began 3 months back after he returned from pilgrimage from Saudi Arabia. He had low grade fever with evening rise of temperature and night sweats, loss of appetite and some weight loss. There was no history of contact with tuberculosis and no other family member was affected.
- Infected needlestick injuries
Needlestick injuries (NSI) are a relatively common occurrence within the healthcare setting. In this article, we outline the risks involved and how to go about managing a needlestick injury.
- Clinical aspects of Lyme disease
This article presents a brief history of a patient presenting in the early stage of Lyme disease, an emerging infectious disease in Europe. The reader is directed towards making a clinical diagnosis. Consideration should be given to rashes (including atypical ones), evolution of symptoms, investigations, treatment and prevention.
- Infective hepatitis
This case-based discussion focuses on the presentation of a normally healthy 47-year-old man with jaundice, fatigue and fever following a visit to Thailand. It considers the approach that needs to be taken when dealing with infective viral hepatitis, including comprehensive history taking, assessment of risk, differential diagnosis, investigation, treatment, and follow-up to monitor and manage both acute and chronic complications.
- Investigation and management of chronic hepatitis C virus infection
Chronic infection with the hepatitis C virus (HCV) is a major and increasing health problem affecting approximately 185,000 people in the UK in 2009. Longstanding hepatic inflammation can lead to progressive fibrosis that may result in cirrhosis, decompensated liver disease and/or hepatocellular carcinoma. Effective antiviral treatment exists which can cure over 50% of patients. This case-based discussion will focus on the presentation, clinical findings, key investigations and management of a 56 year-old lady with newly diagnosed chronic HCV.
- Treatment of anaphylaxis
You are called to see a 28-year-old man on the medical admissions unit. He is a type 1 diabetic in hospital with a community acquired pneumonia. The nurse tells you that he is looking increasingly unwell and has just been given IV amoxicillin as treatment for the pneumonia. He is not known to have any drug allergies but has not had amoxicillin before. You advise that the antibiotics are stopped immediately and you assess Mr D. On arrival, Mr D does not look well – he is having difficulty speaking to you and appears slightly confused. His respiratory rate is 25 breaths/minute and oxygen saturations are 85% on air. Examination of his chest demonstrates a marked wheeze throughout. Further examination shows him to have cool peripheries and you record a blood pressure of 80/55 and feel a weak, thready pulse, rate 124bpm. His capillary refill time is 3 seconds and he is becoming increasingly drowsy during your assessment. You suspect a diagnosis of anaphylaxis to the IV amoxicillin. How should you manage this patient?
- Urticaria and angiodema
Urticaria describes short-lived slightly raised, itchy red patches anywhere on the body. Angioedema describes swelling occurring slightly deeper in the skin and mucous membranes. Urticaria may affect more than 20–25% of the population at some point in their lives. Most patients suffer both urticaria and angioedema although one may predominate in some patients. Urticarial patches are often pale in the centre and vary between a few millimetres across to 10cm or more across. These patches can sometimes become confluent giving the impression of diffusely swollen, itchy red skin. They can affect any area of the body and usually last from 30 minutes to as long as 48 hours or more. Apart from the discomfort of the itching, systemic symptoms are usually absent in simple urticaria and angioedema. Some patients may feel tired. When the individual patches of urticaria last longer than 36 hours, or are associated with bruising, then an inflammation of cutaneous blood vessels should be suspected as part of a cutaneous vasculitis. The latter is often associated with arthralgia, myalgia and mild fever.
- A febrile and confused patient
The confused and febrile patient is a staple of acute medical takes. The differential is often wide, ranging from the common but relatively trivial to the rare but life-threatening. Below we present a typical case, discuss the causes not to miss, how to recognise these patients and how to ensure that they are managed optimally.
- Pyrexia of unknown origin
We present a case of a 30-year-old German student who was admitted with persistent fever, weight loss, joint pains and headache. She was originally referred for an oncology opinion by her GP, who was suspicious of an underlying haematological malignancy. She complained of 3-months intermittent fever, night sweats, fatigue and approximately 4kg weight loss. A rash had developed on her lower limbs and she described poorly localised abdominal pain, together with joint pains in her hands, feet and knees. In addition, she reported episodes of severe headache that resolved spontaneously. She had a past history of vitiligo with no significant family history. She took no regular medications, had no allergies, did not smoke and reported minimal alcohol intake. She was not sexually active and had no other risk factors for HIV infection. She had spent 6-months working as an anthropologist in West Africa in 2006. On examination her temperature was 38.0 and she looked comfortable. She was pale with a diffuse petechial rash affecting both her lower limbs. Her spleen was palpable 2 fingerbreadths below the costal margin. Joint examination was unremarkable. General physical examination was otherwise normal.
- Anaemia in chronic kidney disease: a pitfall
Anaemia is common in chronic kidney disease (CKD), and the prevalence increases as the glomerular filtration rate (GFR) progressively falls (1). Using the World Health Organisation criteria for anaemia of haemoglobin (Hb) less than 13 g/dl in men and less than 12 g/dl in women, 15.3% of patients with CKD 3 to 5 were anaemic in a UK population (2). Higher or normal Hb levels are associated with reduced hospitalisation, less severe left ventricular hypertrophy and improved quality of life, up until Hb of 13 g/dl is achieved (where anything above is associated with worse outcome (3)) which makes it important to recognise and treat. The mechanism of anaemia in CKD is multifactorial, including impaired erythropoietin synthesis, haematinic deficiency and anaemia of chronic disease. Iron deficiency may occur due to reduced absorption from the gut, due to inflammation (4) which is common in CKD. This is thought to be associated with inflammatory cytokines inducing hepcidin transcription, which inhibits iron absorption (5). Functional iron deficiency can also occur due to the use of erythropoesis stimulating agents (ESAs) which deplete the iron pool by increasing erythropoeisis (5), often defined by a transferrin saturation (TSAT) of below 20% (6). Guidelines such as the National Institute for Clinical Excellence (NICE) recommend the need for replenishing iron stores before commencing ESA therapy in those who are iron deficient (7). However, it is important to remember that iron deficiency is also an important manifestation of gastrointestinal (GI) malignancy and other GI bleeding lesions. Upper GI malignancy was reported as 5.5% and lower GI malignancy 10% in the presence of iron deficiency anaemia (IDA), in one study (8).
- Clinical aspects of urinary tract infections
Suspected urinary tract infection (UTI) is the second most common indication for antibiotic use in primary and secondary care. Inappropriate antibiotic use is associated with toxicity, emergence of resistant bacteria, selection of pathogenic organisms (such as C difficile), and poor clinical outcome. This article reviews the spectrum of disease, diagnosis, and clinical management.
- Diarrhoea in the returned traveller
With increasing travel, worldwide from the UK, travel related pathologies increase in importance. Before a travel related diagnosis can be made, an appropriate history of travel is vital. We highlight, both reasons why and how to undertake an appropriate travel history. Furthermore, we discuss aetiology, and management of travel-related diarrhoea and in particular we focus on shigellosis, its pathophysiology, and recent changes in anti-microbial management.
- Fever in a returning traveller from Africa
We describe a clinical case of a patient returning to the UK from Africa with fever in the context of a viral haemorrhagic fever (VHF) outbreak in 2014-15. A logical approach to the returning traveller is required, including a prompt VHF risk assessment in accordance with the UK Advisory Committee on Dangerous Pathogens (ACDP) guidance. Although important, cases of imported VHF are very rare in the UK with malaria being a much more common imported infection. Malaria can be severe and should be considered in every returning traveller with fever.
- Pneumothorax caused by Clostridium ramosum bacteraemia
Here we will present and discuss the case of a 33 year old injecting drug user presenting with sepsis and left-sided pneumothorax. He had recently been investigated and treated for a proximal right leg deep venous thrombosis (DVT). He was subsequently found to have Clostridium ramosum bacteraemia secondary to the infected DVT with subsequent development of multiple large septic pulmonary emboli (PE) and left-sided pneumothorax.
- Relapsing clostridium difficile infection and the curative role of faecal transplant
This case-based discussion focuses on an elderly patient with multiple comorbidities who had over seven months of relapsing Clostridium difficile infection with diarrhoea. Treatment with all available pharmacological options including intravenous immunoglobulin therapy was unsuccessful. He received a faecal transplant via nasogastric tube to achieve cure after failure of all previous interventions. The case demonstrates the refractory nature of C. difficile infection in high risk populations and presents the important and perhaps underutilised role of faecal transplantation as a relatively low-cost curative intervention. The case highlights the importance of appropriate and targeted antibiotic use in clinical practice considering the high morbidity and mortality associated with severe C. difficile infection.
- An unusual case of acute kidney injury
We present an unusual case of severe acute kidney injury in a young diabetic patient. The case highlights the severity and complexity of managing renal failure in obese diabetic patients.
- Differential diagnosis of infectious genital lesions
Genital lesions are a common condition (>20 million cases worldwide each year) (1), which may present to a variety of medical specialties including Accident and Emergency, Genito-urinary medicine, Obstetrics and Gynecology or Primary Care. Lesions may have an infectious or non-infectious aetiology, and it is crucial that doctors perform a structured history and examination to optimize management and prevent misdiagnosis. The most common infectious genital lesion is genital herpes or warts, although the prevalence of previously uncommon conditions (eg: syphilitic lesions) is gradually increasing. This article will discuss the salient points of medical review and clinical investigation to help physicians pinpoint the diagnosis and optimise patient management.
- Prescribing in chronic kidney disease
Nursing staff ask you to review a 70-year-old woman on the ward who has developed melaena.She was admitted 3 days ago with chest pain, and treated with aspirin, clopidogrel and enoxaparin 45mg twice daily (1mg/kg). You notice that her admission creatinine was 140µmol/l, and wonder if dose adjustments need to be made at this level.
- Management of acute renal failure
A 73-year-old woman presents with a 2 month history of myalgias, joint pains and bloody nasal discharge and over the last few days has developed a skin rash and dyspnoea with associated haemoptysis. Blood tests show a serum potassium of 7.2mmol/l, urea 44mmol/l and creatinine 1223µmol/l.
- Clinical management of acute renal failure
A 60-year-old housewife presents to the emergency department with a three week history of cough, breathlessness and lethargy. She also complains of occasional epistaxis. She was previously well and on no regular medications. On examination she is febrile and looks unwell. Auscultation of her chest reveals bibasal crepitations. She also has a widespread purpuric rash. Heart sounds are normal. A Chest radiograph reveals bilateral infitrates. Her sputum is blood stained.
- Peri-operative management of cadaver renal transplant
A 56-years-old Caucasian male weighing 87 kg was admitted to the Transplant Unit for a cadaver kidney transplant. He has been on haemodialysis for the past 14 months. The results of his cardiac screening tests were satisfactory and are all in date (within the past 18 months). He last had haemodialysis 2 days ago. There was no recent history or symptoms suggestive of new onset cardiac co-morbidity. On examination his chest was clear and he had no ankle swellings. He had raised internal jugular venous pulse, but was otherwise well. ECG showed mild left ventricular strain. It is important to check that by the scheduled starting time of surgery, the patient would have fasted for more than 4 hours.
- Renal trauma
Renal trauma occurs in approximately 1–5 % of all trauma. The kidney is the most commonly injured genitourinary organ, with a male to female ratio of 3:1. The majority of renal injuries can be managed conservatively, although occasionally it can be acutely life-threatening. Approximately 10% of patients sustaining abdominal trauma have an injury to the genitourinary tract (1-4).
- Nephrotic syndrome
A 54-year-old gentleman presented to the renal clinic complaining of increasing swelling of 6 to 8 weeks duration, mainly in his legs and around his eyes. He had gained four kilogrammes of weight. He had no history of upper respiratory tract infection or any other illness preceding these symptoms. He did not give a history of rash, haemoptysis, joint pains, nose bleeds or hearing problems. He was started on furosemide by his GP with no response. He had a past history of well controlled hypertension and asthma. At the time of presentation he was on lisinopril, cetrizine, salbutamol inhalers and salmeterol inhalers. He smoked about 30 to 40 cigarettes per day. On examination, he had a pulse of 86 bpm and his blood pressure was 133/95 mmHg. His JVP was not raised. He had gross bilateral pitting pedal oedema extending up to the abdominal wall. The rest of the general and systemic examination was unremarkable.
- Assessment of acid-base balance
A 43-year-old woman presents to the emergency department with diarrhoea and vomiting. She is under regular follow-up of the renal department due to Stage 4 Chronic Kidney Disease (CKD). The cause of her renal disease was autosomal dominant polycystic kidney disease and her last creatinine level in the clinic was 280mmol/L (estimated GFR = 17 ml/min/1.73 m^2)
- Gout: treatment and renal complications
A 68-year-old gentlemen presented to A&E with a 1-week history of being “off his legsâ€. On examination he was drowsy and febrile. He was admitted and treated for a urinary tract infection as he had a neutrophilia and the presence of blood and protein in his urine. In the past, he had been treated for hypertension, a stroke and non-specific c arthritis. Over the 5 days subsequent to admission, he developed oedema, severe hypoalbuminaemia and proteinuria and his C-reactive protein (CRP) rose to over 500. Blood cultures came back negative for organisms. It was noted that asymmetrical synovitis and bilateral knee and shoulder effusions had developed. Joint aspiration revealed negatively birefringent crystals and no organisms were seen or cultured. Tophi were noted on his pinnae and distal interphalangeal joints. A diagnosis of acute polyarticular gout with associated nephrotic syndrome was made. He received colchicine orally and underwent arthroscopy and lavage of his knees and shoulders. His symptoms and nephrotic syndrome resolved and he was discharged on regular allopurinol. He recovered well after a period of rehabilitation in a community hospital.
- Chronic kidney disease and its complications
A 59-year-old Afro-Caribbean gentleman presented with a 3-month history of gradually worsening tiredness, breathlessness, sickness and itching. Five-years ago he was found to be hypertensive by his GP and was given lifestyle modification advice but was lost to follow-up. He was a smoker with a 40-pack-year history. On admission his BP was high at 180/100. ECG showed a left ventricular strain pattern. The chest X-ray was reported as showing mild cardiomegaly. Urine dipstick showed 2 protein. Lab tests revealed sodium 136 mmol/L, potassium 4.5 mmol/L, urea 40.1 mmol/L, creatinine 830mmol/L, haemoglobin 6.6 g/dL, calcium 2.05 mmol/L, phosphate 3.5 mmol/L, and glucose 6.0 mmol/L. An USS of kidneys demonstrated bilaterally small kidneys (bipolar length less than 8 cm with thin cortices) with no evidence of hydronephrosis. He was deemed to have reached end-stage renal disease, the cause of which was uncertain, and he was initiated on haemodialysis.
- Acute kidney injury (AKI) - diagnosis, investigation and management
Around 20% of hospitalised patients develop AKI (1). The NCEPOD (National Confidential Enquiry into Patient Outcome and Death) review of patients who died in hospital with AKI reported that only around 50% of patients received (what they determined as) good AKI management (2). It is vital to understand how to diagnose, investigate and manage AKI appropriately in order to lessen the high morbidity and mortality associated with this condition.
- Infections in renal transplantation
A 48 year old gentleman with adult polycystic kidney disease received a deceased donor renal transplant. His maintenance immunosuppressive therapy was tacrolimus and mycophenolate mofetil. He presented 8 months post-transplantation with fever and profuse diarrhoea for the previous 5 days (no blood), abdominal pain and lethargy. Initial investigations demonstrated an acute increase in serum creatinine from his baseline, together with a low white cell count and platelets. Here we discuss common infections in renal transplantation patients.
- Renal disease in myeloma
Myeloma is the second commonest haematological malignancy and is often complicated by renal involvement. We present a case of renal disease in myeloma, and describe the principles behind investigation and management.
- Nephrotic syndrome diagnosis & managment
The term “dropsy†has been known about since ancient times and means oedema. Nephrotic syndrome has been described by various eminent scientists through the ages as either the result of excessive loss of protein from the kidney or excessive salt and water accumulation due to the chronic states of heart failure and liver cirrhosis. The most notable consequence of continued proteinuria is expansion of body water leading to oedema.
- Severe Combined Immune Deficiency (SCID)
Severe Combined immunodeficiency syndrome (SCID) is a rare and serious type of inherited immune deficiency resulting in poor function of the immune system. A SCID diagnosis is a medical emergency which requires early treatment. This article aims to increase awareness, enabling early diagnosis and specialist referral for potentially lifesaving treatment.
- Angioedema - case-based discussion
Recurrent angioedema, due to oedema of subcutaneous tissue, may present to primary or secondary care. Laryngeal angioedema can be life-threatening. Causes include idiopathic or spontaneous angioedema (with or without urticaria), drugs including angiotensin converting enzyme inhibitors (ACE-I), allergy, and rarely C1 inhibitor deficiency. Salient features in the history can help to determine aetiology facilitating appropriate treatment.
- Microscopic haematuria
A 22-year old man presented to the surgical admissions unit with a 2-week history of abdominal pain. The pain was peri-umbilical and intermittent in nature. He had no history of haematemesis, haematochezia or melaena stool. He also had a 4-month history of a generalized purpuric rash that was mainly on his extremities. He had no urinary tract symptoms. He denied any history of sore throat or joint pains. His medical history was not significant, and he was taking no medication.
- Chronic kidney disease - mineral bone disease
A 59-year old female, with end-stage renal failure (ESRF) secondary topolycystic kidney disease (APKD) on continuous ambulatory peritoneal dialysis (CAPD), was seen as part of a routine follow-up in outpatients.She complained of tingling around her mouth, as well as numbness andtingling in her fingers. She had been diagnosed with APKD in 1987 and had had 18 months of CAPD before a deceased donor renal transplant in 1992 which failed after 15 years, necessitating her return to CAPD. Her medication consisted of an ACE-inhibitor, a calcium channel blocker, levothyroxine,an active vitamin D analogue and a calcium containing phosphate binder. Her only other medical conditions were hypertension, hypothyroidism andprevious partial parathyroidectomy.
- Diagnosis of nephrotic syndrome
A 30-year old man presented with ankle swelling and progressive weight gain. He was subsequently found to have heavy proteinuria for which a diagnosis of nephrotic syndrome was made. This case discussion describes the process of diagnosing nephrotic syndrome, the management of the consequences of the nephrotic syndrome and the process for identifying the underlying cause.
- Assessing renal function - the eGFR explained
Mrs X is a 62-year old, white, non–insulin-dependent patient with diabetes. She was diagnosed with diabetes in 1992. Her medical history includes hypertension and asthma. She takes ramipril 5 mg daily. She is a non-smoker and does not drink alcohol. She is attending diabetic clinic for the first time. Your consultant asks you for a thorough review, including evaluation of her renal function.
- Isolated proteinuria - how to screen, how to measure, how to interpret
Proteinuria is an important indicator of underlying kidney disease and its presence and quantity is an independent risk factor for both progression of CKD and cardiovascular disease. Routine urinalysis for screening purposes is recommended for high risk patients particularly those with diabetes or hypertension. Furthermore changes in proteinuria have been suggested as a surrogate outcome for kidney disease progression. This article will review the evaluation of a patient with isolated proteinuria and the way of screening and measuring for proteinuria will be explained here.
- Renal anaemia - diagnosis and therapy
Erythropoietin deficiency is the major cause of anaemia in chronic kidney disease (CKD), but it is import to rule out other causes of anaemia first before diagnosing renal anaemia. Recombinant human erythropoietin (EPO) has been used for more than two decades in the treatment of renal anaemia, but as much it is accepted that it improves the physical and mental health of patients with renal anaemia the long-term benefits with regards to cardiovascular morbidity and mortality remain less clear. Consequently the target haemoglobin still remains a controversial topic. Tailoring anaemia management to each patient remains a challenge to the attending physician.
- Immunosuppression in renal transplantation
Kidney transplant is the best available treatment for end-stage renal disease. It leads to improved quality of life, prolonged survival and is cost effective compared to dialysis. Despite the above advantages it is related to significant morbidity and mortality due to opportunistic infection and other complications as a consequence of immunosuppression. Here we discuss three renal transplant cases that illustrate some of these complications.
- Drug treatment of liver disease
A 55 year old man presents to A&E feeling unwell and is found to have fast atrial fibrillation and aspiration pneumonia. Upon taking a history you find that he has a heavy history of alcohol consumption throughout his adult life. On examination you find that he is icteric, spider naevi are present and he has ascites. His blood tests show a platelet count of 105, INR 1.4, Albumin 32, bilirubin 65, ALT 40, Alk Phos 105. This article will help you decide on the most appropriate treatment, dosing regimen, monitoring and possible adverse events in the management of this patient.
- Anaemia in chronic kidney disease: a pitfall
Anaemia is common in chronic kidney disease (CKD), and the prevalence increases as the glomerular filtration rate (GFR) progressively falls (1). Using the World Health Organisation criteria for anaemia of haemoglobin (Hb) less than 13 g/dl in men and less than 12 g/dl in women, 15.3% of patients with CKD 3 to 5 were anaemic in a UK population (2). Higher or normal Hb levels are associated with reduced hospitalisation, less severe left ventricular hypertrophy and improved quality of life, up until Hb of 13 g/dl is achieved (where anything above is associated with worse outcome (3)) which makes it important to recognise and treat. The mechanism of anaemia in CKD is multifactorial, including impaired erythropoietin synthesis, haematinic deficiency and anaemia of chronic disease. Iron deficiency may occur due to reduced absorption from the gut, due to inflammation (4) which is common in CKD. This is thought to be associated with inflammatory cytokines inducing hepcidin transcription, which inhibits iron absorption (5). Functional iron deficiency can also occur due to the use of erythropoesis stimulating agents (ESAs) which deplete the iron pool by increasing erythropoeisis (5), often defined by a transferrin saturation (TSAT) of below 20% (6). Guidelines such as the National Institute for Clinical Excellence (NICE) recommend the need for replenishing iron stores before commencing ESA therapy in those who are iron deficient (7). However, it is important to remember that iron deficiency is also an important manifestation of gastrointestinal (GI) malignancy and other GI bleeding lesions. Upper GI malignancy was reported as 5.5% and lower GI malignancy 10% in the presence of iron deficiency anaemia (IDA), in one study (8).
- Clinical aspects of urinary tract infections
Suspected urinary tract infection (UTI) is the second most common indication for antibiotic use in primary and secondary care. Inappropriate antibiotic use is associated with toxicity, emergence of resistant bacteria, selection of pathogenic organisms (such as C difficile), and poor clinical outcome. This article reviews the spectrum of disease, diagnosis, and clinical management.
- Post-transplant lymphoproliferative disease
Organ transplantation is one of the pillars of modern medicine. The increasing success of organ transplantation means the chances of Foundation doctors encountering a patient with a transplant on the acute medical or surgical take have never been higher. The immunosuppression used in transplantation increases the risk of developing a wide range of infectious complications. Post-transplant lymphoproliferative disorder (PTLD) is an important post-transplant complication that Foundation doctors should be aware of. In the vast majority of cases PTLD is caused by the Epstein-Barr Virus (EBV). We present a case of EBV-driven PTLD complicating renal transplantation followed by a brief overview of PTLD.
- The kidney and HIV
A 45 year old female, was referred to the Renal outpatient clinic with renal impairment (eGFR 57 ml/minute/1.73m2) and proteinuria, with urine albumin:creatinine ratio (ACR) of 163 mg/mmol. She was asymptomatic, with no systemic symptoms of joint pain, fever, rash or weight loss. Examination was unremarkable, normal jugular venous pressure, normal heart sounds, clear chest and no peripheral oedema.
- Ureteric complications after renal transplant
Kidney transplant is the best available treatment option for most patients with end-stage renal failure. Although relatively uncommon, complications affecting the ureter of the transplant kidney can cause significant morbidity. Here we discuss two cases that illustrate typical ureteric complications associated with renal transplantation.
- An unusual case of acute kidney injury
We present an unusual case of severe acute kidney injury in a young diabetic patient. The case highlights the severity and complexity of managing renal failure in obese diabetic patients.
- Fits, faints & funny turns
‘Fits, faints and funny turns’ describe often dramatic and frightening symptoms and are common reasons for people to seek medical attention. These terms usually refer to a period of transient loss of consciousness. The underlying diagnosis of transient loss of consciousness is often inaccurate or delayed. Patients may falsely be labelled as having a diagnosis of epilepsy and consequently other potentially life threatening diagnoses may be missed. Foundation year doctors are often the first people to assess patients presenting with such symptoms, for example whilst clerking during the acute medical take, when reviewing ward patients during on call shifts, and whilst working in the Emergency Department or community. This assessment provides a great opportunity to utilise the key skills of being a doctor, including taking and performing a thorough history and examination, formulating a differential diagnosis, selecting appropriate investigations and presenting findings to senior colleagues. The aim of this article is to discuss the differential diagnoses for patients presenting with transient loss of consciousness, and to highlight important features in history taking, examination, investigation and management.
- An Acute Cerebellar Syndrome
Patients presenting with acute ataxia are commonly seen on medical wards, and the differential diagnosis is broad. Here we present an unusual case of acute ataxia caused by listeria cerebellitis. We discuss the history, examination, investigation and management of the case, before considering cerebellar anatomy and the common causes of an acute cerebellar syndrome.
- Assessment of patients complaining of headache
Migraine is extremely common. 6% of men and 15% of women have migraine fulfilling the official criteria of the International Headache Society, while up to 70-80% of the population have milder headaches that probably have a similar mechanism, and certainly respond to the same range of analgesic drugs (1). The vast majority of patients attending neurology clinics complaining of headache without other symptoms or any physical abnormalities have migraine; often the best approach is to ask about headache, abdominal pain and even motion sickness in their adolescent years! A small proportion do have other significant diseases, including subarachnoid haemorrhage, meningitis, temporal arteritis, cervical spondylosis, idiopathic intracranial hypertension, sinusitis and variants of migraine such as cluster headache and the various hemicranias.
- Bacterial menengitis
We describe a case of an elderly lady found poorly responsive at home, in whom the final diagnosis was pneumococcal meningitis. She later developed a cerebral abscess: an uncommon complication but one that all doctors should be aware of given its implications for treatment. We discuss learning points key to assessment of such patients by junior doctors: (1) neurological assessment of a confused or drowsy patient with emphasis on localising the cause of their poor conscious level; (2) initial differential diagnosis in terms of aetiology, including whether their poor conscious level is due to a primary neurological condition or secondary to a systemic illness; (3) understanding the CSF results; (4) specific points regarding risk factors and complications of pneumococcal meningitis, the commonest cause of bacterial meningitis in adults.
- Diagnosis of epilepsy
Epilepsy affects 50 million people worldwide (1), with a prevalence of 4-10 per 1000 in the UK (2). Ten percent of people will have a seizure during their lifetime, without necessarily developing epilepsy (1). The risk of an individual developing epilepsy in their lifetime is 3-5% (2). Essentially, regardless of your chosen specialty, it is likely you will encounter patients with epilepsy, either during an acute seizure event or as a co-morbid condition. Like any chronic medical condition, the aim of management is to allow patients to live life as normally as possible: indeed, this is the case for the majority of patients, with up to 70% becoming seizure-free on monotherapy (3,4).
- Transient ischaemic attack (TIA)
A 78-year-old man attends the medical admissions unit via his GP. Yesterday he noticed weakness and clumsiness of his right hand with slurred speech lasting for 50 minutes. This did not concern him and he had only mentioned it to his GP during a routine check-up. He tells you that he feels fine and doesn’t understand “what all the fuss is aboutâ€. His previous medical history includes type 2 diabetes and hypertension. He takes amlodipine 5mg od, ramipril 10mg od on repeat prescription.
- Management of Wernicke-Korsakoff syndrome
A 48-year-old lady was brought to the accident and emergency department in an agitated and confused state. Friends confirmed that she had a regular high alcohol intake. A diagnosis of delirium tremens was made. She was admitted to a medical ward and was started on an alcohol detoxification regimen. Her physical symptoms of alcohol withdrawal settled, but it was apparent that she had difficulty walking, with a broad-based and unsteady gait. Although this improved, she also had ongoing memory difficulties. She could not fit nd her way around the ward and had difficulty recalling events since her admission. A CT head scan showed cerebral atrophy and an MRI scan showed no additional pathology.
- Management of acute stroke
An 80-year-old woman was found lying on the floor by her daughter and when the paramedics arrived, her eyes were deviated to the left, she had a right-sided hemiparesis, with a Medical Research Council (MRC) grade 1/5 weakness of the upper and lower limb and she was aphasic. There was no evidence of head injury. She was in sinus rhythm with a rate of 80 beats per minute, blood pressure of 170/100mmHg and capillary glucose of 5.7mmol/L. There were no bruits or murmurs audible on examination and she had no abnormalities on respiratory or abdominal examination. You are called to assess the patient in the emergency department.
- Subdural haematoma
A 79-year-old man is brought into the Accident and Emergency department by his son after sustaining a head injury during a fall 2 hours previously. He has been increasingly confused and unsteady on his feet. On examination, he appears drowsy with a right sided hemiparesis and an ipsilateral dilated pupil. How would you assess and manage his condition?
- The head-up tilt-table test: a diagnostic tool for vasovagal syncope
A 32-year-old sales manager was referred by her consultant neurologist to a specialist falls and syncope unit for further evaluation of transient loss of consciousness. She had experienced episodes of blackouts, occasionally with twitching movements, and was incontinent of urine on one occasion. The neurologist had performed an MRI of her brain and an EEG, neither of which demonstrated any abnormalities. She had been unable to work as two of her blackouts occurred during boardroom presentations and her job also involved driving long distances.
- Early management of ischaemic stroke
An ambulance paramedic crew phones the emergency department to state that they are bringing in a 65-year-old man with right hemiparesis and dysphasia. The patient is maintaining a patent airway and is haemodynamically stable. You consider what to do while awaiting his arrival to the resuscitation room.
- Treatment of status epileticus
A 17-year-old man is brought into A&E by ambulance having been fitting for 10 minutes. He does not appear to have a past history of epilepsy. You are a SHO with no senior support immediately to hand. He has already received rectal diazepam (given by the paramedics), and his pulse and blood pressure are currently stable, as is his oxygen saturation.
- Generalised convulsive status epilepticus
A 48 year old man is brought to A&E by his partner. You are on call for medicine and have been asked to see him. He had his first fit earlier today and now has had a second seizure whilst waiting to see you which has not stopped by itself. The Sister in A&E asks whether you could please see him immediately. On examination there are brisk jerking movements of both arms and legs with accompanying loss of consciousness. He is apyrexial and is not known to have previously had seizures. What do you do?
- Encephalitis
A 32 year old right handed lady is brought to the hospital with a 3 day history of fever, confusion and one witnessed episode of generalised tonic clonic seizure. There is no significant past history of note. There is no history of foreign travel. She is not on any medications. Clinical examination demonstrates a GCS of 14 (E4, M6, V4). There is no focal neurology of note.
- Internuclear ophthalmoplegia and brain stem stroke
The case is that of an 86 year old lady, Mrs. G, who presented to the stroke/ neurology unit complaining of diplopia, having attended Accident and Emergency. That morning she had awoken with 'a heavy feeling in her head', and as she had got out of bed to walk to the bathroom she noticed that she was unable to focus on things and was seeing double. She had been well the previous evening before going to bed.
- Differentiating cervical cord compression from Guillain-Barre syndrome
This article gives a brief history of a case of weakness and sensory disturbance, involving all four limbs, presenting to the medical admissions unit. This is followed by a discussion about which symptoms and signs can help to identify cervical cord pathology or a polyradiculopathy such as Guillain-Barre Syndrome (GBS). In particular, the features that may indicate an acute spinal cord compression requiring emergency management are highlighted.
- Investigation & management of idiopathic intracranial hypertension
This case focuses the presentation, investigations and management of patient with Idiopathic intracranial hypertension. We emphasise the importance of early recognition, diagnosis and treatment of Idiopathic intracranial hypertension to prevent serious complications like visual loss.
- Motor neuron disease
Mr Smith is 72 year old retired teacher who has been electively admitted to the Care of the Elderly ward with a 6 month history of progressive lower limb weakness. He now states he has difficulty swallowing. Your consultant is concerned he may have Motor Neuron Disease and wants to investigate him further with respect to this. You are the F1 and have been asked to clerk him, what do you need to be aware of?
- Does my patient need nerve conduction studies?
What is a nerve conduction study? The terms nerve conduction study (NCS) and electromyography (EMG) are often used interchangeably but are separate parts of a neurophysiological examination. In the UK, medically qualified specialists called clinical neurophysiologists usually perform or supervise these tests. In this article, we give a brief introduction to the basic of NCS and EMG. A detailed account is beyond the scope of this paper but the reader is directed to the references for further information.
- Childhood epilepsy in the UK: a review
One of the most discussed, debated, and studied topics of paediatric neurology is that of epilepsy. It is a challenge to diagnose, treat, and prevent the complications of this condition and much research has gone into improving the outcome of the lives of those affected by different forms of epilepsy. This review aims to broadly cover the majority of the aspects of childhood epilepsy and to develop an understanding of the difficulties one faces when dealing with these complex neurological conditions. It will be particularly useful for those new to the field, or those who would like a general overview of relevant information in one easy-to-read place.
- Acute neuromuscular weakness.
A 37 years old lady presented to the medical admissions unit (MAU) with a seven-day history of increasing pain, limb weakness and altered sensation in her hands and feet. This case based discussion focuses on the assessment of acute neuromuscular weakness, and the relevant differential diagnosis, investigations and management.
- Trigeminal neuropathy
We present a case where a patient presented with a trigeminal neuropathy (numbness to the lower right lip and tongue). Initially, the intracranial course was investigated only. The patient returned 14 months later with further symptoms. The extracranial course was then investigated and a lesion was found invading the nerve, by which time the patient had developed multiple metastasis to the lungs and brain. We discuss the course of the cranial nerve and the most common abnormalities leading to a trigeminal neuropathy. When patients present with a cranial nerve neuropathy it is essential to investigate both the intra cranial and extracranial courses of the cranial nerves.
- Baclofen toxicity in an elderly patient
A case report is being described of a 64-year old lady with multiple medical problems including renal impairment, who presented with episodes of loss of consciousness (LOC) and increasing drowsiness. After a series of medical tests to exclude neurological and cardiological causes for the LOC was done, it was suspected that the baclofen medication was causing these events. On tailing off the baclofen there was a dramatic improvement in the patient’s condition with full recovery to her previous medical condition. In this discussion, an overview of the drug balcofen including its uses, side effects, toxicity and management of the latter is explored in more detail.
- Cerebral venous sinus thrombosis
Headache is a very common complaint encountered by junior doctors. Cerebral venous sinus thrombosis is an important pathology to consider as early recognition and prompt treatment improve outcome. The case described here illustrates the importance of a thorough history and examination, with further discussion around investigation and management.
- Persistent vegetative state
A 21-year-old man was brought in to the A&E department by ambulance following an out of hospital cardiac arrest. He had overdosed on alcohol and methadone. He was successfully resuscitated in A&E. His cardiovascular and respiratory examination was normal. He was unresponsive to pain and generally hypertonic. He was initially intubated and then went on to have a tracheotomy. He recovered normal breathing and was weaned off the ventilator. However, he remained unresponsive to voice or pain. A CT head showed a tight brain, consistent with hypoxic damage. There was no evidence of space occupying lesion, haemorrhagic or ischaemic cerebrovascular attack. Over the next few days he became awake, with his eyes open and closed resembling sleep–wake cycles. He still did not respond to visual, auditory, tactile stimuli or pain. He made occasional non-purposeful grimaces and sounds. During the course of his admission, a percutaneous endoscopic gastrostomy (PEG) tube was inserted to provide nutrition. He received regular physiotherapy and his posture was passively changed frequently to offload pressure points. He had occasional infections of chest and urine, which were treated with antibiotics. He was diagnosed with persistent vegetative state and after about 6 months of hospital care he was transferred to a care home specialising in caring for such patients.
- Investigation and management of a possible first presentation of multiple sclerosis
This case presents the investigation and management of a patient with a first episode of neurological dysfunction that could be the first presentation of multiple sclerosis. A discussion of the rationale for the investigations and treatment follows, and we discuss communication with a patient and planning for her long-term care.
- A totally reversible cause of mobility loss in an elderly patient
An 80-year-old man presented with an 8-weeks history of progressive lower limbs weakness of lower motor neuron-type, rendering him unable to weight bear. There was no history of back pain or trauma, and he denied bladder or bowel problems. Investigations including blood tests and MRI of the spine were normal, while CSF examination revealed increased protein level. Nerve conduction studies showed evidence of proximal conduction block, suggestive of inflammatory demeylination. Our patient responded well to immune suppression with intravenous immunoglobulin and oral steroids. He became mobile with a rolator within 2 weeks and independently mobile after 4 weeks of starting treatment. The clinical diagnosis was chronic inflammatory demyelinating polyneuropathy (CIDP). CIDP can be thought of as a subacute or chronic onset Guillan–Barré syndrome (GBS). CIDP is probably under diagnosed in the elderly. It needs to be considered in all elderly patients with progressive loss of mobility.
- Cerebral toxoplasmosis
Collapse of unknown cause is a presenting symptom often encountered by junior doctors on the medical assessment unit. This presentation generates a number of possible diagnoses. One of the potential diagnoses is cerebral toxoplasmosis, the most common opportunistic infection of the central nervous system in HIV positive patients. The case of Ms TW will be presented which illustrates the initial difficulties in diagnosis, the chosen treatment regimen, follow-up and length of treatment.
- Diagnosis and management of Parkinson's Disease dementia
Idiopathic Parkinson's Disease (PD) is the most common neurodegenerative disorder. It usually presents between the fifth and seventh decades and has a prevalence of 150 per 100,000. Cognitive decline directly attributed to PD, known as Parkinson's Disease dementia (PDD), can affect up to 40% of those with PD. Risk factors for PDD include older age of onset of motor symptoms and co-morbid depression. Consequently, Foundation doctors should be alert to the symptoms of both cognitive impairment and depression in patients with PD. Management of PDD includes identifying and reducing exacerbating factors and effective communication with patients and carers.
- Supranuclear palsy
Progressive supranuclear palsy (PSP), also known as Steele-Richardson-Olszewski syndrome, is an uncommon neurodegenerative disease which often starts in middle and late life, and is frequently misdiagnosed as Parkinson's disease (1). PSP is characterised by a predominantly axial Parkinsonism with head retraction and a poor response to levodopa. Other classic features include an early onset of postural instability and falls together with paralysis of downward gaze. Cognitive impairment and dementia is well documented in PSP but a presentation with dementia prior to the motor features is rare. We present a case of PSP that presented with cognitive impairment progressing to a dementia picture for 4 years before the onset of the typical motor features of PSP.
- Painful neuropathy
The case of an elderly diabetic man with gradually progressive bilateral foot pain is presented. The pain was burning in character, worse at rest and associated with absent ankle jerks and symmetrical reduction of pinprick sensation in a stocking distribution. After investigations to rule out alternative causes, a diagnosis of painful diabetic axonal polyneuropathy was made. He did not tolerate gabapentin, but amitriptyline was successful in reducing the intensity of his pain.
- Guillain-Barré: don't wait for the saturations to drop!
This case will discuss the care of a patient with Guillain–Barré syndrome. It will include revision of the presentation and treatment of the syndrome, and illustrate the importance of recognising the early warning signs of impending respiratory compromise as a junior doctor.
- Management and investigation of coma on a post-operative patient
This case-based discussion focuses on an independent 73-year-old lady presenting with coma 6 days after a right total hip replacement. The management of coma is discussed with emphasis on the acute resuscitation and differential diagnosis. This complex case demonstrates that using a systematic and multidisciplinary approach allows appropriate management of a patient even when the aetiology is unknown.
- Vertebral artery dissection
This case-based discussion focuses on a previously fit and well 38-year-old lady, 2 weeks post-partum, presenting with two seizures post-neck manipulation and discusses presentation, causes, diagnosis and management of vertebral artery dissection.
- Gluten-induced ataxia
The immunological response to ingested gluten in genetically susceptible individuals was first described by Marsh in 1995. Although gluten-induced enteropathy (coeliac disease) is the commonly recognised presentation, isolated neurological dysfunction, especially ataxia, has been well documented. We present a patient who had established coeliac disease and had been fully treated with no enteropathy for 10 years. After so many years of being symptom-free, the patient presented with ataxia. In the absence of any other cause, the ataxia was thought to be related to gluten sensitivity, which was proven through laboratory and radiological investigations. The case is interesting due to the way it presented as ataxia after several years and the absence of any associated gastrointestinal symptoms from coeliac disease.
- Benign epileptic syndromes of childhood
Benign epilepsies refer to a group of epilepsies in which remission and lack of significant neurologic sequelae is expected in the majority of patients. These disorders are idiopathic, occur in otherwise healthy children, and usually have strong genetic links. They include generalized and focal onset epilepsies. In this article we have presented the childhood benign epilepsies according to the age of onset, starting from the neonatal period.
- Partial Horner's syndrome secondary to facial trauma
We describe an unusual and important presentation of Horner's Syndrome and discuss the possible sequelae of this particular pathological process. The need for vigilance and a high index of suspicion in assessing those presenting similarly is highlighted.
- Management of the patient with Parkinson's disease on the acute take
Parkinson's disease (PD) is the second commonest neurodegenerative disease after Alzheimer's disease and affects about 2% of people over the age of 80. Although the incidence rises with age, however, it is not exclusively a disease of older people. The diagnosis of PD and initiation and monitoring of treatment should be undertaken by a specialist, however, people with PD frequently need to see their GP and are often seen on the general medical or surgical take (either as a result of their PD or for unrelated conditions) therefore the non-specialist still needs to have an understanding of this common condition. Common causes of deterioration and distress in PD can be avoided or quickly managed by the savvy doctor and the aim of this article is to give you the tips you need to avoid the common pitfalls in the management of this complex condition.
- Vaginal discharge and genital tract infections
A 21 year-old patient presented at the clinic complaining of malodorous vaginal discharge, described as “offensive fishy-odourâ€. She does not complaint of any vulval or vaginal itching, pain with intercourse or soreness. She is sexually active with one partner and uses oral contraceptive pills. She doesn’t report any episodes of intermenstrual bleeding, post coital bleeding or abdominal pains. History of regular menstrual periods. Physical examination revealed white/grey discharge in the posterior vault.
- Insertion and removal of Intrauterine devices
Mrs CH, 32 years of age, Gravida 2, para 2 presents to the emergency gynaecology clinic. She approached her GP about her inability to feel the threads of her IUD. Her GP referred her to secondary care as threads of the IUD were not visible on speculum examination. Her last menstrual period was one week ago. She wishes to continue with the IUD for contraception. How will you approach this case?
- Postnatal depression
Mrs M is a 32 year old in hospital following the birth of her third child. She delivered three weeks ago. The delivery was a difficult one and her child is currently on the Special Care Baby Unit. Although her child is progressing well, for the last two weeks Mrs M has been tearful, not engaging well with her child when she visits, looks dishevelled, and is convinced her baby will die despite reassurances from members of your team. You are the FY doctor looking after Mrs M’s child – what do you do?
- The initial investigation of infertility
A 34 year old woman has been trying to conceive for 1 year with no success. Neither herself nor her 32 year old male partner have been responsible for a pregnancy in the past. Further questioning reveals that they have been having regular intercourse at 2-3 day intervals throughout the month. The woman has regular cycles, bleeding for 4 days of every 28, with no menorrhagia or pelvic pain. Neither have ever knowingly had an STI and both are fit and well with no significant past medical or family history. The male partner has a BMI of 32, and the female 29. They do not have occupational exposure to any chemicals, radiation or driving long distances and neither takes medications. They consume less alcohol than the recommended maximum weekly limit on average, but the woman smokes 5 cigarettes a day.
- An incidental laparoscopic finding
A 33 year old Caucasian lady presented to the gynaecology emergency unit with a seven week history of amenorrhoea and a three day history of left iliac fossa pain. This was a spontaneous conception and previously she had had two first trimester miscarriages following in vitro fertilisation (IVF). A hysterosalpinggram prior to her current pregnancy had suggested a non-patent left fallopian tube.
- Therapeutic options in the management of pre-eclampsia
A 30 year old woman presented pregnant at 8 weeks gestation. Her booking blood pressure was 110/70 mmHg and her BMI was 21. She had a medical history of insulin dependent diabetes mellitus for 18 years but was otherwise well and on no medication other than insulin. She had no family history of hypertensive disorders in pregnancy. She subsequently developed pre-eclampsia, presenting at 32 weeks gestation with a 10 hour history of severe headache, blurred vision and epigastric pain. She had been vomiting for 6 hours. Examination revealed a blood pressure of 170/95 mmHg and urine dipstick showed protein. Her BM was 7.6. On examination she had marked ankle oedema and right upper quadrant tenderness. Blood tests showed ALP and ALT were markedly raised.
- Appendiceal mucocoele
A 43-year-old caucasian lady presented to the gynaecology department at our institution with a 6-month history of right iliac fossa pain and deep dyspareunia on the right side. These symptoms were associated with menorrhagia and irregular periods.
- Hyoscine-N-Butyl Bromide (Buscopan) Causing Uterine Hypercontractility Following An Abruption
Uterine hyperstimulation is a potentially serious complication of labour induction, but may also occur as a side-effect of other medications not used for this purpose. We present a case of uterine hyperstimulation as a proposed consequence of Hyoscine-N-Butyl Bromide (Buscopan) use for ureteric colic in a 32-year-old pregnant patient.
- Recognising caesarean scar ectopic pregnancy - an uncommon but life threatening condition
A 34 year old lady attended the emergency department at 6 weeks gestation with mild vaginal bleeding. Her medical history included Type 1 Diabetes for which she was on insulin. She had one child aged 6 years born by emergency caesarean section.
- Chickenpox in pregnancy
We discuss a case relating to the development of primary varicella zoster infection, known as Chickenpox during pregnancy. This is an uncommon scenario within the United Kingdom Caucasian population, but one where incidence is increasing due to migrating populations. This case highlights the importance of a sound understanding of primary varicella zoster syndrome during reproductive age for clinicians especially those in General Practice, Obstetrics and Gynaecology and Occupational Health. Knowledge includes prevention methods, diagnosis and subsequent management, which play a role in preventing the attributed significant morbidity and mortality attributed to it. This article will focus on these issues and provide a resource to clinicians.
- Early pregnancy with right frontal lobe oligodendroglioma
Hyperemesis Gravidarum (HG) is characterized by intractable nausea, vomiting and dehydration and affects about 0.5-2% of pregnant women. HG is considered a rare complication of pregnancy, but because nausea and vomiting during pregnancy exist on a spectrum, it is often difficult to distinguish this condition from the more common form of nausea and vomiting experienced during pregnancy known as morning sickness. HG tends to start in the first trimester of pregnancy and last significantly longer than morning sickness. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they give birth to their baby, and sometimes even after giving birth. A Foundation doctor working in Obstetrics and Gynaecology will definitely encounter women with HG. It is important to bear in mind other diagnoses which may present with similar symptoms.
- Ectopic pregnancy - presentation and management
Ectopic pregnancy is a common complication of early pregnancy. Failure to consider the diagnosis in women of childbearing age can lead to misdiagnosis, substandard care and catastrophic consequences. Trans-vaginal ultrasound scan and serum ßhCG play a major role in diagnosing and managing these women. Management options include medical or surgical treatment dependent on ultrasound scan findings, serum ßhCG levels and the clinical condition of the patient.
- Female urethral catheterisation
A thirty eight year old teacher presented to A&E with a short history of abdominal discomfort and inability to pass urine for 12 hours. She had recently been referred to the gynaecology outpatient clinic with abdominal distension and pressure symptoms. She had been diagnosed with fibroids and placed on the waiting list for a hysterectomy with ovarian conservation. She was white British with a BMI of 38. She had been commenced on a gonadotrophin analogue (Goseralin 3.6mg sc) as pre-operative preparation with the aim of shrinking the fibroids.
- A complicated case of giant vulval condylomata in pregnancy
We present a case of massive condylomata in a pregnant patient complicated by brittle diabetes and mental health issues where a large exophytic mass covered the vulvae and precluded vaginal delivery. Surgical resection was performed following patient request and disclosure of suicidal ideation. The patient received a caesarean section at 36 weeks due to concern over potential perineal scaring and diabetic issues. There was no evidence of recurrence.
- Review of congenital heart disease in pregnancy
RF, a 25 year old primigravida, was referred to the joint obstetric and cardiology clinic at a tertiary centre due to her history of CHD. She had been born with a congenital bicuspid aortic valve and aortic coarctation. She underwent a coarctation repair at 3 days of age.
- Postpartum seizure as a result of dilutional hyponatraemia during labour
Although the aetiology of postpartum seizures is diverse, dilutional hyponatraemia is an extremely rare occurrence not often considered by clinicians (1). We present such a case linked to possible excessive fluid intake during labour in an otherwise uncomplicated pregnancy with no significant past medical history.
- Operative vaginal delivery: Are forceps always better than a Kiwi Omnicup?
After centuries of use in obstetrics, have forceps and vacuum deliveries become a dying art? For example, following a number of poor outcomes with Kielland’s forceps in the 1970s, their use has no longer been taught to obstetricians, with the result that usage was abandoned in some units, while rigorous training and use continued elsewhere (1). Contemporary trends in operative vaginal delivery show increasing numbers of vacuum deliveries and corresponding decreasing numbers of forceps deliveries worldwide (2). In the UK the overall rate of operative vaginal deliveries is between 10 and 13%. This rate has remained stable over many years compared with caesarean section rates, which have continued to climb. It is difficult to determine exactly why forceps have fallen out of fashion and been replaced by Ventouse (vacuum). Although Kiwi Omnicup (vacuum delivery) is associated with less perineal trauma, it has a higher failure rate than forceps. Could this be contributing to the caesarean-section increase rate? A safe operative vaginal delivery requires careful assessment of the clinical situation, clear communication with the patient and healthcare personnel and operator expertise in the chosen procedure. It is crucial to anticipate any complication such as shoulder dystocia, postpartum haemorrhage or an obstetric anal sphincter injury.
- Ovarian torsion - a gynaecological emergency
A 31 year old female attends the emergency department with a 7-hour history of severe right sided pelvic pain. She reports a constant crampy background ache with intermittent waves of stabbing pain lasting minutes at a time, which she rates at 10/10 in severity. She also reports new onset nausea and has vomited twice.
- Selective termination in multiple pregnancy
We present a case of a Mono-chorionic Mono-amniotic twin pregnancy where one twin was diagnosed with severe bilateral ventriculomegaly and possible agenesis of corpus callosum at 20 weeks gestation while the second twin showed signs of growth restriction. The options of conservative management and selective termination of the abnormal foetus were discussed with the couple bearing in mind poor prognosis for both twins. The couple opted for selective termination of the abnormal foetus which was carried out in a tertiary centre. Subsequent scans showed improved growth parameters and placental function for the surviving twin. The pregnancy itself was complicated by pre term pre labour rupture of membranes at 26 weeks gestation which was managed conservatively. The patient went on to have a spontaneous normal delivery at 32 weeks gestation which was uneventful.
- Azoospermia
Infertility is defined as a couple’s inability to conceive after 1 year of regular, unprotected sexual intercourse. (1) It is estimated to affect 1 in 7 heterosexual couples in the UK, with male factors identified in approximately 30% of couples, 16% of those males are found to be azoospermic. (2, 3) Azoospermia is defined as the complete absence of sperm from the semen, as opposed to aspermia which is the complete absence of semen. This article will focus on the investigation and management of azoospermia. 1) Aetiology of Male Infertility, the causes of male factor infertility will be described to provide the relevant basic science necessary to comprehend the subsequent case histories. 2) Case Histories, six real-life cases of azoospermia will be described. 3) Discussion, utilising the NICE Guideline ‘CG156 Fertility: Assessment and treatment for people with fertility problems’, (2) the investigation and management of men presenting to the infertility clinic with azoospermia will be analysed. 4) Conclusion, a summary of the appropriate investigation and management of male infertility as advised by NICE.
- Investigations and management of recurrent miscarriages
Recurrent miscarriage is defined as the loss of three or more pregnancies. It is a heterogeneous condition that has many possible causes; more than one contributory factor may underlie the recurrent pregnancy losses. Recurrent miscarriage affects 1% of couples who are trying to achieve a successful pregnancy. Because the incidence is higher than expected of chance alone (0.34%), a proportion of couples with recurrent miscarriage have a persistent underlying cause for their pregnancy losses.
- Palliative care in gynaecological malignancy
Palliative care in gynaecological malignancies can pose particular challenges in managing distressing symptoms and the effects of the cancer and treatment on psychological and psychosexual functioning that requires a multi-disciplinary approach as illustrated by the following case.
- Diabetes in pregnancy
In England and Wales, around 2%–5% of women will be affected by diabetes during prgnancy (1). Diabetes affects carbohydrate metabolism which necessitates immediate lifestyle modifications. In pregnancy, diabetes can play a huge impact on the wellbeing of both the foetus and the mother. The National Institute of Clinical Excellence (NICE) estimated that approximately 87.5% of pregnancies complicated by diabetes are as a result of gestational diabetes, with 7.5% attributed to type 1 diabetes and 5% to type 2 diabetes (1).
- Obesity in pregnancy
Obesity during pregnancy is an increasing problem in current obstetrics and general practice that takes the dimensions of an epidemic. Optimal management of obese patients and use of resourses is of paramount importance. Education of the public regarding the risks of obesity during pregnancy is essential part of preventive medicine, as weight loss before conception results in significant risk reduction (1,3). It is the duty of all health professionals involved with the care of women of childbearing age, to assess, inform and advice them regarding the risks of obesity and strategies to overcome the problem, with dietary and physical exercise being the most important aspects. During pregnancy, specialist care and close monitoring for complications is essential. This should take place in all levels of care.
- Operative vaginal delivery
Operative vaginal deliveries expedite the delivery of a baby who is believed to be at risk of compromise or when the mother is unable to push it out herself. In the UK, operative vaginal delivery rates have remained stable at 10%–15%. These varying rates reflect different clinical practices and different attitudes in each unit. However, operative vaginal delivery remains an integral and crucial part of the obstetrician’s duties. Low operative vaginal delivery rates may reflect high caesarean section rates, including those performed at full dilatation because of a reluctance to perform operative vaginal deliveries. Although operative vaginal delivery can be hazardous and should be undertaken with care, the difficulty of caesarean section at full dilatation should not be underestimated; it can be extremely difficult and is associated with high maternal morbidity. But, there has been an increasing awareness of the potential for morbidity for both the mother and the baby, following operative vaginal deliveries. Therefore, when offering women the option of a safe operative vaginal delivery, we need to improve our approach to clinical care to minimize the risk of mortality and morbidity; hence minimizing the likelihood of litigation, without limiting maternal choice.
- Early pregnancy unit: management options
In recent years there has been growing interest in defining standardized management algorithms for women with early pregnancy problem, with more treatment as an outpatient basis and the development of more refined diagnostic techniques and therapeutic interventions.
- Investigation and management of secondary amenorrhoea
Regular monthly menstruation is a phenomenon of modern society. Most people associate monthly menstrual loss with functioning fertility hence absence or cessation of menstruation will get most women concerned and seek medical explanation and a possible solution to their problem.
- Anaesthesia and analgesia in obstetrics
Approximately 600,000 women give birth in England and Wales each year. Almost half of these (47%) give birth without intervention of any kind. Annually therefore, nearly one-third of a million women might require the services of an anaesthetist for delivery. According to the National Sentinel Caesarean Section Audit the overall Caesarean section rate for England and Wales was 21.5% . The remaining women will receive intrapartum regional analgesia or anaesthesia for post-partum complications such as manual removal of the placenta or post-partum haemorrhage.
- Benign conditions of the vulva
A 56-year-old woman presents with soreness and a burning sensation over the vulva for 6 months. She was given antifungal treatment without relief of symptoms.
- Gynaecological emergencies
A 29-year-old primigravida presented to A&E with heavy vaginal bleeding and crampy lower abdominal pains at 8-weeks of pregnancy.
- Polycystic ovarian syndrome
Polycystic ovarian syndrome (PCOS) is a common disorder, often complicated by anovulatory infertility and hyperandrogenism, with the clinical manifestation of oligomenorrhoea, hirsutism and acne. Most clinical data suggests a prevalence of 6–7% of the population, with the highest incidence among South Asian women in the UK. Many women with this condition are obese and there is a higher incidence of impaired glucose tolerance, type 2 diabetes and sleep apnoea, than is observed in the general population (1). These cases can present for the first time to gynaecology, endocrinology, reproductive medicine, dermatology, diabetes, general practice, cardiovascular medicine and metabolic medicine.
- Differential diagnosis of common symptoms in pregnancy
Asthma can cause breathlessness, which is often associated with a cough with or without wheezy breathing. The symptoms are usually worse at night, on walking and after exercise.
- Cervical intraepithelial neoplasia, screening and colposcopy
A 38-year-old woman attended her local GP practice for a routine cervical smear. The smear result came back as severe dyskaryosis. She was referred to the colposcopy clinic. On colposcopy examination, the entire squamocolumnar junction was seen. An aceto–white area was seen on application of acetic acid. Colposcopy examination suggested a high-grade lesion. The woman underwent a loop excision of the transformation zone under local anaesthetic. The biopsy confirmed CIN 3 with complete excision of margins.
- Investigating women with postmenopausal bleeding
A 59-year-old lady attended rapid access clinic complaining of a bloodstained discharge in the last 2 weeks for the first time since her menopause at age 53. She has no significant gynaecological history.
- An introduction to urogynaecology
A 52-year-old obese lady (BMI-40), who is menopausal for the past 2 years, presents with a history of leakage of urine on coughing and sneezing.
- Prescribing in pregnancy and breastfeeding
Prescribing in pregnancy and breastfeeding poses many dilemmas for the clinician as there are many factors to consider. This article aims to address these and should equip the reader with the knowledge to council, and prescribe for, such patients confidently.
- Medical problems in pregnancy
The majority of women who become pregnant are healthy and remain so throughout their pregnancy. However, a number of women present with either pre-existing or new medical disorders that might affect their pregnancy. This article focuses - in points - on how to identify and manage common medical problems in pregnancy.
- Assisted Reproduction In Unusual Circumstances
This case highlights the unusual but real clinical and ethical dilemmas faced by both patients and clinicians involved in the treatment of a transgender couple wishing to conceive prior to sex reassignment surgery. We discuss the effects on fertility of taking exogenous sex steroids, the strategies available for conception and the role of the regulatory body the Human Fertilisation and Embryology Authority in maintaining ethical and legal standards.
- Benign Large Gynaecological Masses
Benign gynaecological masses usually present with menstrual abnormalities and pressure symptoms. Clinical examination and relevant investigations aid in the diagnosis. Management should be tailored to suit the needs of the patient. Complications should be promptly recognised and treated. Critical incident reporting of major post- operative complications should be done to learn lessons and prevent recurrence. Effective communication is essential to prevent complaints.
- Endometriosis
Dysmenorrhoea and dyspareunia are common symptoms in gynaecology, endometriosis being high on your differential list. Often diagnosed months to years after the onset of symptoms, endometriosis can be difficult to manage, particularly when involving organs such as bowel or urinary tract and distressing as a cause of infertility. Despite various staging systems, the extent of the disease does not correlate well with pain. In this article we discuss the different management options based on the most updated evidence and reviews. Management of endometriosis must be patient-centred and often involves long-term follow up and trials of various treatments. Reassurance and good communication skills are of utmost importance.
- Hyperemesis Gravidarum
Nausea and vomiting in pregnancy is a common symptom that can cause considerable psychosocial and financial implications but rarely causes morbidity and mortality. This is a common complaint requiring admission in Gynaecology through accident and emergency department and hyperemesis gravidarum is an over-diagnosis in this group. Hyperemesis results in dehydration, metabolic and electrolyte disturbance with increased risk of maternal and fetal morbidity. The pathophysiology is not fully understood but pregnancy hormone fluctuations are thought to play a role. Fluid rehydration and electrolyte replacement with antiemetics are the mainstay of treatment. The case study described here is a common case scenario encountered by junior doctors. The discussion covers the important aspects in detail which includes history taking, physical examination, differential diagnosis, necessary investigations, management and complications of hyperemesis.
- Management Of Abnormal Menstrual Bleeding
Heavy menstrual bleeding (HMB) commonly presents in general practice and, although not usually associated with significant morbidity, it is associated with a significant impact on quality of life issues as well as financial costs to the National Health Service. Over the last 20 years, there have been significant improvements in the way that HMB has been managed: up until the early 1990s at least 60% of women with HMB would undergo hysterectomy - often as a first line treatment (1). With the advent of the Mirena Intrauterine System (IUS), most HMB cases can now be managed effectively in primary care. The development of conservative surgical techniques such as endometrial ablation mean that even those who fail to respond to medical treatment can still avoid undergoing hysterectomy with all of its potential complications.
- Mental Health In Pregnancy
Mental health continues to contribute to significant morbidity and mortality in pregnancy and the postnatal period. Mental health disorders in young women are commonplace and the impact of pregnancy is not to be underestimated. Psychiatric conditions are the second most common cause of indirect deaths in pregnancy at 0.85/100,000 maternities according to the confidential enquiry into maternal deaths (CEMD) (1).
- Post Menopausal Bleeding
This discussion is based on the diagnostic pathway of a fifty seven year old woman who presented to her GP with postmenopausal bleeding. The learning objectives would be to explain the rationale for the different investigations and her management.
- PPH With A Jehovah's Witness
A 36 year old Jehovah's Witness delivered her 4th baby and had a 2.3L post-partum haemorrhage. This case study discusses the antenatal management of the patient, management of the acute bleed and the ethical and legal issues pertinent to patients who refuse blood products.
- Sepsis In Obstetrics
In modern day medicine, sepsis is still a major cause of morbidity and mortality; mortality rate from septic shock being as high as 30-70% (1). Confidential enquiries into maternal deaths (CEMACE) in the United Kingdom found sepsis as the leading cause of direct maternal deaths with a dramatic increase in maternal deaths attributable to group A beta-haemolytic streptococci (GAS) (2). Failure of early recognition of signs of sepsis and delayed treatment were important factors identified. Current strategies of early detection and management of sepsis are highlighted in this review.
- Stress Urinary Incontinence
Urinary incontinence is a common condition affecting up to 50% of women of any age in the UK. It has major psychosocial implications for the woman's life as well as financial implications for the health service. In this article through diagrams and case scenarios we have explored the mechanism behind urinary stress incontinence and approaches to its diagnosis and management. Accurate diagnosis of the type of urinary incontinence is essential to choosing the correct management. Urodynamic studies provide a useful adjunct to a detailed history, examination and urine analysis. Management options for urinary stress incontinence include conservative measures such as weight loss and supervised pelvic floor muscle exercises, medical treatment with Duloxetine and surgical treatments including suburethral slings and colposuspension. Patients who are not candidates for surgery can be offered intramural urethral bulking injections. Two case scenarios illustrate factors involved in diagnosis and choice of treatment. The future for urinary stress incontinence may lie in using autologous stem cells from the patient's own skeletal muscle as urethral bulking agents.
- Surgical Causes of Abdominal Pain in Pregnancy
Abdominal pain in pregnancy is an extremely common complaint and one that as obstetricians and gynaecologists, we see and assess on a daily basis. The cause for pain may be related to the pregnancy or due to physiological changes caused by pregnancy, or the pregnancy maybe incidental. Non-obstetric causes of abdominal pain are equally as important albeit not as prevalent. In this article we provide a brief overview of surgical causes of abdominal pain, pitfalls in their management and a brief description of diagnostic imaging used in pregnancy. Three clinical cases are described to highlight the importance of considering non obstetric causes of abdominal pain. This article enables the reader to gain confidence in the management of abdominal pain in pregnancy, whilst keeping an open mind about its variety of potential causes.
- Skin cancer
A 76-year-old caucasion man was referred by his general practitioner to the dermatology outpatients clinic because of a non-healing skin lesion on his scalp.
- Management of a thyroid nodule
A 56-year-old non-smoker presented with a 2-year history of a swelling in the front of the lower part of her neck. The swelling was of an insidious onset with no significant increase in size and there was no associated discomfort reported. However, occasional pressure symptoms were noted as well as a “feeling of something†in her throat. There had been no weight loss recorded. On examination, she was found to have a 4×3 cm swelling which seemed to be localised to the isthmus and adjacent part of the left thyroid lobe. This classically moved upwards upon swallowing. There was no associated lymphadenopathy. Initial clinical evaluation suggested the swelling to be a thyroid nodule.
- Colorectal carcinoma
A 78-year-old male presented to Accident and Emergency department with a 4-day history of abdominal distension, vomiting and constipation. He had a background history of known diverticular disease. In the last 6 weeks, he had increasing symptoms of loose and frequent bowel motions. He had a history of hypertension and migraine. His sister had a right hemicolectomy for caecal adenocarcinoma at age 65 years. His initial observations showed a temperature of 37.5C, heart rate 110/min, blood pressure 158/87 and respiratory rate 16/min. Blood tests showed a haemoglobin 15.3 g/dl; WBC 14×10^9/L; platelets 667×10^9/L; urea 9.4 mmol/L and a creatinine 123 µmol/L. His plain abdominal X-ray showed signs of large bowel obstruction. He subsequently had a CT scan of the abdomen which showed an obstructing sigmoid carcinoma with no evidence of perforation or metastatic disease. Following his initial resuscitation, he had a colonic stent inserted to relieve the obstruction. Four days later, he had an elective anterior resection with primary anastomosis. He was discharged home 1 week later. Histology confirmed a Dukes B adenocarcinoma of the sigmoid.
- Management of malignant pericardial effusion
A 65-year-old woman presents to the medical admissions unit (MAU) with a 4-week history of progressive dyspnoea, weight loss, swelling over feet and a hacking cough worse on lying down and improving on leaning forward and sitting upright. She was previously diagnosed as having metastatic breast cancer and had recently completed her course of palliative chemotherapy a few months back. She continues on endocrine treatment with tamoxifen. There was no other relevant past history.
- Elective surgery for colorectal cancer - Patient assessment and in-patient management
A 60-year-old bus driver presented to the colorectal clinic with a 6 week history of bright red rectal bleeding and looser stools. There was no history of weight loss and past medical history included asthma, hypertension and hypercholesterolaemia. He takes medication for these and is a long term smoker. Clinical examination revealed a rectal mass and histological analysis confirmed an adenocarcinoma. Blood tests were unremarkable and staging investigations showed no metastatic disease. How would this man’s finess for surgery be assessed? How would he be managed as an inpatient?
- Epidemiology and management of oral cancers
A 65-year old man presented with a 2 month history of a painless ulcer on the left lateral border of his tongue (Figure 1). He is unsure as to whether he has bitten his tongue. He has used topical preparations without any effect. He has a past medical history of hypertension and ischaemic heart disease. He lives alone. He is a retired taxi driver with a 40 pack-year smoking history. He drinks 30 units of alcohol per week.
- Breast lump investigation
Breast cancer is a major health problem and it has an increasing incidence worldwide. It is estimated that 1 in 8 women in the UK will develop breast cancer sometime during their life (1). A diagnosis of breast cancer can impact greatly on patients and their families. It is therefore imperative that through careful history taking, thorough examination, and targeted investigation, a diagnosis can be made and treatment started promptly. This case based discussion focuses on the investigation and management of a 36 year old patient presenting with a breast lump.
- Brain tumour treatment options
As with almost any cancer presentation, brain tumours are a diverse group of diseases with widely varying morbidities, prognoses and treatment options. The most common tumours found in the brain are metastases from an extracranial site (1) - approximately 8.3 per 100,000 compared with 6.6 per 100,000 for primary brain tumours. However, primary brain tumours are the second most common childhood cancer and the most common solid tumour in children (2), with different treatment options and a superior prognosis compared to adult tumours. Treatment modalities for brain tumours include surgery, chemotherapy, radiotherapy and supportive care. This article will give an overview of the care of adult patients with central nervous system (CNS) metastatic disease and some of the more common primary brain tumours including high and low grade gliomas.
- Managing a patient with carcinoma of unknown primary
A 67 year old man presented with fatigue, mild dyspnoea and an aching lower back and rib cage. He was found to have diffusely abnormal bones on imaging and further investigation demonstrated adenocarcinoma of unknown primary site (1). This case-based discussion describes the process of investigation and management of this patient, some unusual features of his case and potential complications of treatment. He remains well more than two years after diagnosis.
- Paraneoplastic syndromes
Paraneoplastic syndromes encompass a heterogeneous group of rare disorders which exist as an indirect consequence of a primary tumour and its metastases. In some cases the syndrome may precede the diagnosis of cancer and an early and accurate recognition of the syndrome is therefore paramount. A case of the neurological paraneoplastic condition ‘Lambert Eaton Myasthenic Syndrome’ is presented here along with a discussion of the relevant investigations and subsequent management.
- Malignancy in teenagers and young adults
Cancer is the commonest medical related cause of death in teenagers and young adults. Overall, it is second only to accidents (1, 2, 3). In the United Kingdom, six teenagers and young adults are diagnosed with cancer every day (1). In 2005, NICE Guidance on Improving Outcomes in Children and Young Adults with Cancer was published and there has been a significant improvement in services. There has been recognition that they require not only specialised care, but also psychological, social, educational and developmental support (3, 4). Here we report a case history of a young woman of 22 with metastatic breast cancer.
- Managment of metastatic lung cancer
Lung cancer is the most common cancer worldwide, and the second most common cancer among men in the UK, accounting for around 14% of all new cases of cancer in males. It is the third most common cancer among women, responsible for more than 11% of all new cases of cancer in females. It has been estimated that the lifetime risk of developing lung cancer in 2008 is 1 in 14 for men and 1 in 19 for women in the UK. It is estimated that, at any one time, there are 65,000 people living with lung cancer in the UK.
- Fertility after chemotherapy
A significant proportion of patients who undergo chemotherapy for cancer become infertile as a result. Following substantial improvements in the management of several solid tumour types, increasing numbers of patients are surviving cancer and chemotherapy. The average age at which people start their families is also increasing, and both factors have led to greater numbers of patients facing chemotherapy related infertility, and the associated social and psychological stress. Here we present two illustrative cases, one involving a woman undergoing adjuvant chemotherapy for breast cancer, and the second a man undergoing chemotherapy for testicular cancer. We will discuss the salient points raised by each case, and in particular, the options currently available for fertility preservation.
- Management of neuroendocrine tumours
A 55 year old gentleman with a long history metastatic Bronchial Carcinoid developed signs and symptoms of Right Heart Failure over a 6 week period. Despite curative surgery ten years previously he had relapsed both in the chest and liver, and had subsequently received a variety of treatments to try to control his disease which had continued to slowly progress. He was admitted as an emergency with increasing shortness of breath and found to have severe stenosis of his right pulmonary artery caused by the growing tumour mass in his chest. The case discusses the subsequent management of this problem and the specialists involved, and also the diagnosis, management and treatment of neuroendocrine tumours.
- Nutrition in cancer patients
Patients with cancer suffer a variety of symptoms. Cancer-associated malnutrition is one of the most common symptoms encountered. It can result from the systemic and local effects of a tumour, the host response to the tumour or advanced anticancer therapies (surgery, chemotherapy, radiotherapy, biological immunotherapy and hormonal treatment). Cachexia often occurs in advanced cancer. It is a multifactorial syndrome characterized by anorexia accompanied by generalized host tissue wasting, skeletal muscle atrophy, immune dysfunction, and metabolic derangements. Cancer patients therefore have the double burden of fighting cancerous cells and finding ways of replacing damaged cells. Although cancer patients often have reduced food intake, alterations in metabolism and resting energy expenditure may also contribute to their nutritional status. Several agents produced in response to the tumour, such as pro-inflammatory cytokines and hormones, have been implicated in the pathogenesis of malnutrition and cachexia.
- Common oncological emergencies
You are an SHO in A&E and asked to see a 70-year-old man with known metastatic prostate cancer stage T4NXM1, for which he is receiving anti-androgen therapy. Over the past month he has been complaining of mid-back pain that radiates around his chest when he coughs. This morning he got out of bed and his legs gave way. He also says that over the last week he has noticed increased urinary frequency and now has developed urinary incontinence.
- Recognition and management of tumour lysis syndrome
Tumour lysis syndrome is a potential complication of chemotherapy, and occurs due to extensive cellular breakdown in patients with bulky, rapidly proliferating and highly treatment-sensitive tumours1. It results in the release of intracellular contents into the circulation, and may lead to metabolic disturbance, renal failure and cardiac arrhythmias. This article will focus on the case of a patient who developed tumour lysis syndrome during treatment for Burkitt's lymphoma. It will aim to highlight the identification of high-risk patients, strategies for prevention, and treatment of the metabolic and renal complications.
- Metastatic carcinoma of unknown primary
Metastatic carcinoma of unknown primary (CUP) accounts for 2–4% of all malignancies. Patients present with metastatic disease, but despite standard investigations, the primary site often cannot be located. The prognosis is poor, except in a few specific subgroups, and response to chemotherapy remains disappointing. Patients often initially present with symptoms of metastatic cancer to their GP or A&E and are admitted to hospital under acute medical or surgical teams for investigation, before being referred to oncology services for treatment once a diagnosis has been made. This case-based discussion illustrates a typical case of a patient who presents with CUP and outlines the process by which the patient should be investigated, and referred to the oncology services. The importance of involving multidisciplinary team members is highlighted and the process of breaking bad news is discussed. The use of novel molecular diagnostic techniques is also described.
- An audit of timely and appropriate prescribing of antibiotics for patients with neutropaenic sepsis
Mortality from neutropaenic sepsis is high if there are delays in diagnosis and initiation of treatment. The primary aim of this audit was to assess whether the location and timing of diagnosis for patients with new onset febrile neutropaenia and neutropaenic sepsis affected the likelihood of receiving appropriate protocol antibiotics.
- Management of the febrile neutropaenic patient
Mrs S is a 44-year-old lady who has been brought in by ambulance to the A&E of her local district general hospital, accompanied by her husband. He contacted their GP when she began feeling unwell early that morning, with rigors and a temperature of 39°C (recorded at home); her GP advised that she come directly to hospital. She is on a long course of chemotherapy for acute myeloid leukaemia (AML) and was discharged from hospital 1 week ago. On arrival in the A&E, Mrs S is flushed and looks unwell. Her initial observations are as follows: pulse 98 beats per minute; BP 95/60; respiratory rate 24; oxygen saturations 95%; and temperature 38.5°C. A urine dipstick revealed a trace of protein and ketones , but no nitrites or leucocytes. Chest X-ray is unremarkable, other than Mrs S's Hickman line in her right subclavian vein. She is commenced on intravenous fluids and given paracetamol for her temperature. You are the FY1 doctor on-call and you are asked to clerk the patient for admission, prior to assessment by the haematology SpR, who is on-call from home; and will be in the hospital in around 45 minutes.
- Malignant pleural mesothelioma
You are asked to see a 68-year-old man who presents to the A&E with a 6-weeks history of worsening shortness of breath, dry cough and accompanying pleuritic pain on the right side of the chest. He has no expectoration or haemoptysis, but has definitely lost weight. He has no significant past medical history and is not on any regular medicines. He has smoked 20 cigarettes per day since he was 18 years old, but stopped smoking 10 years ago.
- Prostate cancer screening: the ongoing debate
A 67-year-old gentleman presented to his GP with worsening lower urinary tract symptoms (LUTs) of poor flow and nocturia. On referral to Urology he was found to have Gleason grades 3 and 4 localised prostate cancer and underwent radical prostatectomy. During his postoperative follow-up for erectile dysfunction he asked me "why is there no screening programme for prostate cancer, when women have both breast and cervical cancer screening?" To which I found that I did not have the evidence to support my answer. Currently there is no prostate cancer screening in the UK. This article outlines the evidence to suggest why no such screening programme exists. After reading this article you will be provided with the evidence to answer such a question should you be asked in the future.
- Investigations and management of lung cancer
Lung cancer is the second most common cancer diagnosed in the UK. The investigations and management of patients with lung cancer remains complex. In the UK it involves a multidisciplinary team approach, which includes close working between respiratory physicians, oncologists, cardiothoracic surgeons, radiologists, histopathologists, palliative care team and specialist nurses. The investigations of patients with lung cancer have also become multifarious, as new technologies such as positron emission tomography scanning, endobronchial or endoscopic ultrasound have acquired wider use. Moreover, the management of patients with lung cancer has become more complex as new chemotherapy and radiotherapy modalities have been developed. The understanding therefore of the modes of presentation of patients with lung cancer is pivotal as it may result in early detection. Moreover the awareness of investigational pathways and therapeutic options remains an important aspect of managing this devastating condition.
- Management of cancer of the oesophagus
Management of oesophageal cancer can be challenging. A case with oesophageal cancer discussed in detail with his management used to illustrate the treatment pathway of a locally advanced oesophageal cancer. This includes assessment of the disease and a brief overview of the treatment options of oesophageal cancer.
- Tuberous sclerosis associated renal cell carcinoma
We present an interesting case of a 20 year old male with Tuberous Sclerosis, a rare autosomal dominant condition characterised by multi-organ hamartomas. This condition is expressed with huge variability across patients, with multiple extra-hamartomatous manifestations including; seizures, learning difficulties, behavioural problems, skin conditions and other multi-organ complications. In addition to the well-documented hamartomas, these patients can present with malignant tumours and here we discuss the unfortunate case of a 20 year old male with an incidental finding of a 65mm renal cell carcinoma picked up on routine Computed Tomography (CT) imaging.
- Absent red reflex in a newborn
An absent red reflex in a neonate is a sign detected by paediatricians and General Practitioners at newborn baby checks. The failure of light to pass through the eye has serious implications for the development of neuronal connections between the eye and the brain. We present a case that exemplifies a typical history and management of this sign.
- Panretinal laser photocoagulation therapy for diabetic retinopathy: practical procedures
Pan-retinal laser photocoagulation (PRP) is a procedure in which laser burns are placed over the peripheral retina, sparing the central macula. It is the gold standard treatment for proliferative diabetic retinopathy (PDR), an advanced stage of diabetic retinopathy characterised by the development of retinal neovascularisation (1,2). PDR is very often asymptomatic and patients may retain good vision despite existing retinopathy hence the need for regular annual photographic screening. PRP has been shown to reduce the risk of severe visual loss by 50% in patients with PDR (2,3). This article demonstrates the use of PRP laser therapy in the clinical setting of a rare case of severe and extensive PDR.
- Ocular complications of marfans & surgical management
Our patient was a 19 year old girl who had a long standing diagnosis of Marfans syndrome. She was myopic and this was corrected with spectacle lenses. She presented to our eye clinic with a two month history of gradually worsening vision in both eyes. On examination she was found to have significantly subluxed lenses in both eyes (ectopia lentis). Dilated fundoscopy revealed normal retinas in both eyes. She was subsequently listed for right lensectomy and anterior chamber lens insertion (to be later followed by the same procedure in the left eye).
- The acute red eye
The acute red eye is a common ophthalmological presentation both in the Accident & Emergency (A&E) department and in the Ophthalmology outpatients’ department. It is caused by conditions ranging from the trivial to the sight-threatening. By considering three hypothetical presentations for the same patient, this article aims to differentiate between the important causes, and hence identify serious disease.
- A case of unusual ocular tumour
The following article describes an interesting case of a uveal tumor. We discuss its presentation, clinical picture, differential diagnosis and management.
- Examination and removal of ophthalmic foreign bodies
A 26-year-old man who works as a mechanic presents to the accident and emergency department complaining of a painful watering right eye. It started 2h ago and he doesn’t recall any FB entering the eye but he was grinding some metal earlier and did not use any eye protection. He is otherwise fit and well, takes no medicines and has no allergies.
- Testing for glaucoma
A 60-year-old Chinese female attends the emergency department with pain, redness and blurred vision in her right eye. She gives a one day history of coloured haloes around lights, vomiting and frontal headache.
- Diffuse choroidal haemangioma associated with Sturge Weber Syndrome treated with proton beam therapy
We report a rare case of diffuse choroidal haemangioma associated with Sturge Weber Syndrome in a young girl. The clinical course and treatment of this condition is discussed and diagnostic clues are highlighted.
- Fitness to drive
The Driving Vehicle Licensing Agency (DVLA) is an Agency of the Department for Transport and has a responsibility to ensure that all license holders are fit to drive. The DVLA set minimum standards for vision, a driver must have good central vision and adequate peripheral vision, if not met the driver must not drive and the license must be refused or revoked. This article summarizes the DVLA vision requirements, provides practical advice and discusses ethical considerations.
- Intra-vitreal injections
Intra-vitreal injections can play a huge role in the management of important ophthalmological conditions. It has become a popular method to manage retinal diseases such as age-related macular degeneration (AMD), diabetic retinopathy and retinal vein occlusion. The development anti-VEGF agents has made a significant impact the management of AMD and other conditions associated with pathological neovascularisation.
- Orthoptic assessment
A systematic method of examining patients with ocular motility disorders will be presented. This will be useful for all doctors including those in Ophthalmology training. We aim to outline an approach which will enable one to grasp the key pointers in the history, as well as ascertaining the relevant signs. A brief quiz has also been included to test your knowledge.
- Age related macular degeneration: focus on wet macular degeneration
Age related macular degeneration (ARMD) is a very common cause of visual impairment in the elderly. This case report describes a very typical scenario and highlights important aspects in diagnosis and management of macular disease which junior doctors in training should find useful.
- An emergency presentation of acute angle closure (AAC)
This article gives a brief history of a case of acute angle closure (AAC) presenting to the Medical Assessment Unit (MAU). This is followed by a discussion about terminology, demographics and predisposing factors, history taking (clinical signs and symptoms), eye examination, differential diagnoses and management strategy. In particular, important findings in a patient presenting with AAC that should not be missed and will aid with the decision process of ‘admit or discharge’ will be discussed.
- Consent in ophthalmology: obtaining consent prior to cataract surgery
Cataract surgery is a commonly performed procedure in the UK. When obtaining consent from patients, the junior doctor should be aware of the information that should be provided and the questions that patients may ask about the procedure. There are established national and local guidelines for obtaining consent available, however, this article aims to present a possible practical application of such guidelines. We use a simple case scenario to demonstrate and explain some of the issues and questions that may arise while obtaining consent from a patient.
- "Doctor, I think I have grit in my eye"
You are an FY2 doctor in ophthalmology, seeing patients in eye casualty. A 37-year-old gentleman walks in with a 3-day history of a red and sore right eye. He felt something go into his eye 3 days ago, while he was at work. He thought he had managed to blink it out at the time, but is still experiencing a gritty sensation in his right eye. He has also noticed that the eye is red.
- Glaucoma
Glaucoma is the world's second leading cause of blindness. Raised intraocular pressure is recognised as one of the major risk factors. Medical and surgical interventions are based on keeping intraocular pressures within normal limits; doing so can help to reduce further visual field loss in the disease. As well as managing the condition it is important to educate patients about their condition to improve concordance and obtain the best outcomes. There are several organisations that provide information and assistance to people with visual loss and are an invaluable source of support for patients.
- Wet age-related macular degeneration
Age-related macular degeneration is a leading cause of blindness in the Western world. It is classified as either dry or wet macular degeneration. Wet macular degeneration is a particularly devastating condition responsible for the majority of blind registration in the United Kingdom. Recent advances in the management of wet macular degeneration are enabling therapies to provide not only stabilisation but also improvement in patients' visual function. This article will provide an insight into the presentation, diagnosis and management of this condition.
- Assessing visual acuity
Assessing visual acuity is an aspect of ophthalmology which is commonly misunderstood. The following article demonstrates how to approach a patient with impaired vision including taking a history, assessing near and distance vision, and how to understand and interpret the results. The ability to accurately assess a patient's visual acuity is an essential skill for all doctors. To assess renal function, one would routinely test blood, urea and electrolyte levels. There is, however, no blood test for the eye and visual acuity is the most sensitive method to ascertain ocular function.
- Orbital apex syndrome secondary to herpes zoster ophthalmicus
We report a case of herpes zoster ophthalmicus complicated by orbital apex syndrome. The clinical course and treatment of the patient is detailed with discussion of hypothesised pathogenesis in the published literature. This case highlights the possible associated ocular complication of herpes zoster ophthalmicus.
- Sudden painless loss of vision: giant cell arteritis.
The following article discusses the clinical presentation, appropriate investigations and the management of giant cell arteritis (GCA). Further, it reviews the social support networks and rehabilitation pathways available for patients with visual loss.
- Central retinal artery occlusion
A central retinal artery occlusion (CRAO) is in some ways the ocular equivalent of a cerebral stroke. It is one of the few time-dependent ophthalmic emergencies. We describe a case of CRAO with macula sparing, which resulted in the patient having preserved central vision and thus reasonably good visual acuity.
- Uveitis
Uveitis comprises a group of related disorders, which can be categorised based on which part of the eye is affected. In this article, we present the case history of a typical patient presenting with acute anterior uveitis, discuss the features that should alert the non-specialist to the possibility of this condition, and describe the management of uveitis in the ophthalmology department. This article mainly focusses on acute anterior uveitis, as it is the most common presentation of uveitis that foundation trainees are likely to encounter, but intermediate and posterior uveitis are also briefly described. We also discuss the most common systemic diseases associated with uveitis, and describe features that should prompt further investigation for systemic disease.
- A classic case of toxoplasma retinitis
We present a classic case of toxoplasmosis retinitis in a 44 year old male, highlighting key aspects of diagnosis and management to help guide clinical practice. Diagnosis is largely clinical so key signs have been explained, and the rationale for the chosen treatment plan, including acceptable alternatives, are also explored. Important differentials, especially in the immunocompromised population, are also discussed and important means of differential testing are addressed. We discuss current knowledge on this subject, summarise key points and present multiple-choice questions for self-testing.
- Paraneoplastic retinopathy: a rare cause of visual loss
Paraneoplastic syndromes are complexes of signs and symptoms in cancer patients. These result from dysfunction of tissues remote from the site of a malignant neoplasm or its metastases. Most of these syndromes occur as a result of ectopic tumour production of a hormone or functional growth factor acting at a distal site; whereas others are believed to involve immune-mediated cross-reactivity between tumour antigens and normal host tissues. Ocular paraneoplastic syndromes can be divided into 2 groups i.e. retinal and optic nerve based. The purpose of this article is twofold; firstly, we describe a case of probable Paraneoplastic Vitelliform maculopathy and discuss this condition in more detail. Secondly, it will remind the clinician of this relatively rare entity. Ocular paraneoplastic phenomena manifest subtle signs and are therefore easily overlooked and misdiagnosed.
- Choroidal granuloma: a case of ocular tuberculosis
Ocular tuberculosis (TB) is a rare manifestation of extrapulmonary TB. We present the case of a 21-year-old female South Asian patient with systemic TB who developed choroidal granulomas in the left eye. Following successful treatment with anti-TB therapy the granulomas resolved forming chorioretinal scars. However, this was complicated by the development of a choroidal neovascular membrane (CNVM) at the site of the scar one year later.
- Penetrating eye injury
Penetrating eye injuries are serious ophthalmic emergencies that can result in severe loss of vision or loss of the eye. Patients who have sustained these injuries present to the emergency department and need prompt assessment and referral to an ophthalmic specialist. A foundation or junior doctor is often the first to diagnose and manage these patients. We present a case of a 28 year old patient who presented with a globe rupture and penetrating eye injury. We discuss the importance of a careful examination and highlight the steps taken in the initial management of these patients. We share the events that occur after referral to an ophthalmologist and the journey a patient goes through when faced with this traumatic injury.
- Contact lens related keratitis
Contact lens wearers frequently present acutely with a painful red eye. This must be assumed to be infectious keratitis when first seen. A number of different pathogens can be involved. Factors that predispose to corneal infection include contact lens wear, trauma, surgery or chronic ocular surface disease. There is an interesting paper published in 2008 on the incidence of contact les related microbial keratitis in Australia. It was concluded that new lens types did not reduce the incidence of disease and that overnight use of any contact lens was associated with a higher risk than daily use. In particular, the risk of microbial keratitis from wearing a contact lens was calculated to be about 1 in 2,500). New lens types did not reduce the incidence of disease. Overnight use of any contact lens was associated with a higher risk than daily use. In summary, the risk of microbial keratitis from wearing a contact lens is about 1 in 2,500. This does not mean that you will lose sight from it. To be more specific, 10% out of that group will lose two lines of vision and therefore, there is a 1 in 25,000 risk of visual loss. Hence, a specific practical approach to the management of these patients is required to avoid permanent, sight threatening complications. This paper presents one case history and discusses appropriate management for a non-specialist by question and answer. It then briefly illustrates a further two cases with different aetiologies.
- Management of retinal vein occlusion
Retinal vein occlusions are categorised based on the location of the thrombus and subsequent haemorrhages, and whether this has caused ischaemia. Treatment options vary based on the type of vein occlusion and ischaemic status and include observation, laser treatment and intravitreal injections. Prognosis varies from complete resolution of vision to painful and sight threatening complications.
- Assessment of orbital fractures
Orbital trauma presents regularly to accident and emergency departments in the UK, usually secondary to assault and road traffic accidents. Careful evaluation of the injury is paramount. Appropriate treatment and referral to specialty care is necessary to manage these trauma patients. Consequences of orbital trauma could include persistent symptomatic diplopia, enophthalmos and loss of sight. We present a case of orbital fracture that required surgical management. Additionally, we discuss clinical assessment of orbital fractures, classification of orbital fractures and indications for surgical management.
- Double trouble: when diplopia strikes, think twice
We describe a case of unilateral third and fourth cranial nerve palsy with proptosis, in a 67-year-old female. This was preceded by a two-week history of frontal headaches, neck pain and malaise. Blood results revealed a normal ESR of 36 mm/hr and a raised CRP of 28mg/L. The patient was treated with high dose oral prednisolone for suspected giant cell arteritis (GCA), however, an aneurysmal pathology was considered most likely. Urgent magnetic resonance angiography and venography found no acute vascular pathology or retro-orbital abnormalities. A temporal artery biopsy performed on day 7 of oral steroids was found to be positive for active GCA. Within one month of oral steroid therapy, the diplopia, right ptosis and proptosis completely resolved. One year later, she has had no further episodes of diplopia or visual disturbance, and remains on a low dose of tapering oral prednisolone.
- An ethical dilemma in ophthalmology understanding the patient's agenda
We present the case of a young woman presenting with retrobulbar neuritis in which the disease course becomes increasingly bizarre until it is realised that the correct diagnosis is that of malingering. We discuss the pitfalls in diagnosing and treating retrobulbar neuritis generally, as well as the medico-legal minefield of non-organic visual loss. Some tests for diagnosing non-organic visual loss are discussed as well as the importance of remaining professionally detached in these and other similar cases in which the patient's actions can have profound effects on our emotions.
- Proptosis with a swollen optic nerve: an optic nerve tumour
It is not uncommon to be confronted with a patient with either proptosis or a swollen optic nerve. There are instances when these two important clinical signs may present together. In this case one wishes to highlight the significant elements of the history, the essential clinical signs to elicit, and an appropriate process to follow in order to reach a correct diagnosis and management approach.
Oral and Maxillofacial Surgery
- Common paediatric orthopaedic conditions
An 8-year-old boy presents with a painful right elbow following a fall from a swing onto an outstretched hand. The child is not known to be on the child protection register and is otherwise fit and well. On examination there is extensive swelling around the elbow. The child is reluctant to let you examine the elbow due to the pain, yet the radial and ulnar arteries are found to be present but weak, with a increased capillary refill time of 4 seconds. The child is neurologically intact distal to the injury. A lateral X-ray of the right elbow shows a “fat pad sign†on the lateral view and a visible fracture in the distal humerus with a distal fragment partially tilted and displaced posteriorly. It is not possible to get an anteroposterior (AP) view due to pain. In children under 10 years old, fractures of the elbow are the fourth most common fractures, and the second most common long bone fractures, second only to fractures of the distal radius and ulnar in their incidence. The majority of these injuries are supracondylar fractures, with a peak incidence in children 6–8 years old. The most common cause of injury is for the child to fall onto an outstretched hand and the elbow to be forced into either a valgus or varus direction.
- Acute compartment syndrome: explaining the confusing facts
A 23-year-old man sustained an inversion injury to the left ankle during a football competition. He felt a pop in his lower leg and developed immediate pain and a limp. The anterolateral left leg became increasingly painful 8 hours after the injury. He was seen at a local emergency department, but radiographs of the ankle were negative. He was discharged with the diagnosis of an ankle sprain, but he continued to have increasing pain and swelling in the anterolateral leg, which was not relieved by analgesics. At 24 hours after his injury, he was sent by his General Practioner (GP) to the emergency department.
- Management of acetabular fractures and pelvic injuries
The majority of pelvic ring fractures are due to high-energy blunt trauma. Disruption of the retroperitoneal arteries and venous plexus with compromise of pelvic ring integrity can lead to massive blood loss. We provide a case presentation of such an injury to better guide Foundation doctors in their management of such injuries. Fractures of the acetabulum involve the joint surface of the pelvis. In terms of presentation and management these are different injuries compared to pelvic ring fractures and this is explored in the case presentation.
- Orthopaedic radiology cases
A 27 year old man presents to A&E following a motor vehicle accident. He complains of severe pain and swelling in the right knee, and is unable to weight bear. On examination, his knee is tender, swollen and has severely restricted range of movement. There are no visible wounds around the knee. Antero-posterior and lateral view radiographs of the right knee are performed.
- Septic arthritis of the paediatric hip
We present a case of a 12-year-old girl with a 2-day history of pain in her right hip. Key elements in her history and examination reveal the cardinal features of septic arthritis and are then confirmed on further investigation. Paediatric hip pain is very common and has many different causes. One of the most concerning and significant causes is septic arthritis. Diagnosis of this disorder can be difficult. Our aim in this case based review article is to describe the management by example. We recommend using a scoring system to decide which children are most at risk of septic arthritis, in order to guide initial management. We also describe the surgical treatment for septic arthritis of the hip, once the diagnosis has been made.
- Synovial chondromatosis of the distal radioulnar joint
Synovial chondromatosis is a rare condition, which results in the formation of loose bodies within joints, with associated pain and limitation in the range of movement and function. The disorder has been most commonly observed in the knee, the hip and the elbow. A case of the condition affecting the wrist is presented here, together with a brief discussion of the management of the condition.
- The locked knee
A 25-year-old man attends his local A&E department. He presents with a painful swollen knee which is unable to bear weight. He gives a history of having sustained an injury while playing rugby for his club. The injury occurred when he was tackled. His foot became stuck in the soft ground and his upper body twisted as he fell to the ground. He describes a popping noise coming from his knee as he fell. He was carried from the pitch and was driven by a friend to his flat. Over the next 2 hours his knee became very swollen and stiff. The pain became worse. At this stage his flatmates drove him to his local hospital.
- Insufficiency fracture
A 65-year-old lady develops severe lower back and right flank pain. She is admitted to a surgical ward for suspected renal colic.
- Discitis: the cause of a PUO
A 69-year-old gentleman was admitted with a presumed lower respiratory tract infection (LRTI) for which he received treatment on a general medical ward. After a failure to respond to first line antibiotic therapy, the clinical assumption was inferred that this was due to infection with an atypical organism. On deeper clinical questioning the patient revealed mild back pain of short duration that commenced following a recent camping trip. After an unsuccessful response to numerous antimicrobials, investigations were initiated for a pyrexia of unknown origin (PUO). After multiple negative investigations, including plain films of the lumbar spine, a radioisotope (indium) WCC scan was performed.
- Back pain
A 46-year-old woman attended the A&E Department with a 7-day history of severe back pain. Radiation of pain down her left leg started 3 days before attending the hospital. The pain started when she bent down to lift up a heavy flower pot in her garden. She took paracetamol and Ibuprofen without much help with her symptoms. The pain gradually worsened, and she finds it difficult to move from her bed to the toilet and back. There is no history suggestive of bowel and bladder disturbance.
- Systemic lupus erythematosus
A 28-year-old Afro-Caribbean female teacher presents to clinic with an ongoing history of joint pains going back 2 to 3 years. She has recently become more tired and has noted that she becomes short of breath when walking 100 metres, sometimes with sharp stabbing chest pain which comes and goes. Last summer, when on holiday, she developed a facial rash for the first time, which has now disappeared. She has noted that her hands become more stiff and painful in the winter months or when working with cold or frozen material.
- Osteomyelitis
A 42-year-old man was presented to the A&E department with a temperature of 39°C, feeling unwell. Heart rate was 110bpm, blood pressure 100/60mmHg, respiratory rate 24 breaths/minute, oxygen saturation on room air 90%. He had no chest pain, or abnormal neurological findings. Chest auscultation and ECG were normal. He smoked 20 cigarettes/day, and his past medical history was unremarkable. He sustained an open fracture of his left tibia and fibula 8 months previously. This was managed with an ankle spanning external fixation, and open reduction internal fixation of the fibula. The external fixator was removed 4 weeks before presentation at the A&E, and the patient was mobilising with a removable ankle brace. He had pain in his distal tibia and a pus discharging sinus (Figure 1) had developed in the last few days. Radiographs of his left tibia were requested (Figure 2). What is your assessment? How should this patient be managed?
- Scleroderma
A 42-year-old woman was admitted to the Medical Admissions Unit with dysphagia that had worsened over the last few months. Ingesting liquids was particularly problematic. She lost a stone in weight over several months. She denied any other gastrointestinal symptoms. She lives with her husband and recently started to be out of breath while doing household chores. When questioned, she reports that her fingers turned pale on exposure to the cold and that her skin had become thickened over the last few months. Various soothing creams and lotions did not help. She started to experience difficulty opening her mouth lately. On examination, there was sclerodactyly, telengiestasia, calcinosis cutis, microstomia and scleroderma limited to face and hands. A case of Limited Cutaneous Systemic Sclerosis is suspected as the likely diagnosis.
- Vertebroplasty for osteoporotic vertebral fractures
A 70-year-old lady with Parkinson's disease had a mechanical fall and developed acute low back pain. The pain was sufficiently severe to stop her from moving and she was on the floor for several hours before being found by a carer who brought her to the local A&E department. Six years previously she had sustained a crush fracture of the T12 vertebra which had resulted in a prolonged inpatient episode due to pain and reduced mobility.
- Open fracture of tibia and fibula
A 61-year-old male, was brought to the A&E department at around 1am with injury to his right leg. He was under the influence of alcohol and a slow moving motor vehicle hit his left leg, while he was crossing the road. He fell to the ground and could not get up as his left leg was deformed and painful. When the ambulance arrived he was conscious and coherent and he complained of pain in his left leg, which was deformed. A puncture wound was also noted.
- Dupuytren's contracture
A 56-year-old man presents complaining that he cannot get his right ring finger straight.
- Congenital diaphragmatic hernia - a neonatal challenge
Congenital diaphragmatic hernia (CDH) is a developmental defect of the diaphragm in which the abdominal contents enter the thoracic cavity. Optimal early management of the patient is critical to prevent complications. As multicentre randomised controlled trials in CDH are lacking, a consensus statement, issued by the CDH EURO Consortium, was produced with the hope of standardising management of CDH in European countries (1). Baby LM had an antenatal diagnosis of a large congenital diaphragmatic hernia. We present the initial days of her life with the challenges she faced, discussing the important management points.
- Group B streptococcal meningitis in the newborn
The management of both late and early onset of disease is not dissimilar but the source of infection is of interest. The preventive strategies of Group B Streptococcal (GBS) infection in neonates and the complications of GBS meningitis are discussed.
- Infections & necrotising enterocolitis in newborn Infants
Sepsis and necrotising enterocolitis are the most prevalent, yet potentially preventable causes of serious perinatal morbidity and mortality within the neonatal period. 1 in 10 deaths in infants born <32 weeks gestation is due to infection (1). There is a wide range of conditions leading to illness in the neonatal period, but gestation and age at presentation are important factors in terms of the key morbidities, and infections are normally described using these categories. Premature or preterm delivery (<37 completed weeks gestation) is associated with different risk factors to those born at term. Early Onset Sepsis (EOS) occurs in the first 2-3 days of life, whereas Late Onset Sepsis (LOS) occurs thereafter and is usually caused by organisms acquired after delivery.
- Intra-osseous access
A 23 week old girl with a one day history of high pyrexia was presented to the emergency department by her parents who had awoken to find her with an extensive non-blanching purpuric rash. On admission, the infant appeared acutely unwell and was clinically shocked. Urgent circulatory access was required. Peripherally shut-down, gaining peripheral venous access would have been difficult and time-consuming. Intra-osseous (IO) access was secured enabling bloods to be taken and fluids to be administered.
- The child with cough & temperature - what is going on?
We present a case study of a 2 year old boy who developed a pulmonary abscess after completing treatment for pneumonia. Learning points including the assessment of the febrile child, use of clinical judgment in reassessing delayed clinical response, the investigation and management of pneumonia, pleural disease and pulmonary abscess in line with national guidelines.
- An approach to abnormal bruising in the child for the junior doctor
Dermatological injuries, particularly bruising, are the earliest and most common findings in cases of physical child abuse. (1-3) When accidental bruising is so common in children, how can the junior doctor recognise pathological bruising and differentiate between accidental and non-accidental bruising? This article presents the case of a seven-year-old boy with bilateral bruising to the ears: a pattern highly suggestive of non-accidental injury. The importance of a systematic and unbiased history is emphasised, and a list of key questions to ask is provided. The reader is also made aware of some additional history taking goals and documentation requirements in such cases. On a practical note, the distinguishing features of accidental and non-accidental bruises are explained, and a list of differential diagnoses for bruising is provided. The article concludes with a guide on choosing appropriate initial investigations and summarises the outcome of the clinical case.
- Childhood syncope
Syncope is a sudden, self-limited loss of consciousness due to transient global cerebral hypoperfusion. Up to 15 percent of children experience a syncopal episode prior to the end of adolescence (1). It is a common reason for presentation to both general practice and emergency departments, and is therefore a condition that is likely to be encountered during foundation years training. The aetiology of syncopal episodes in children is most often benign, but they can occur as the result of more serious (usually cardiac) disease, with the potential for sudden death.
- Headaches in children
Headaches are common in children. In the majority of cases children suffer from the primary headaches, i.e. migraine and tension type headache. For the foundation year doctor/general practitioner presented with a child with headache, the clinical priority is to identify those with a serious underlying pathology (secondary headache). The following article illustrates two cases in which focused history and examination were paramount in eliciting red flags that suggested an underlying cause, which in turn lead to further investigations, diagnosis and treatment.
- Meconium aspiration syndrome
Meconium aspiration syndrome (MAS) occurs when an infant passes meconium prior to delivery and in addition commences breathing in utero resulting in inhaled meconium. Both these events can be triggered by a degree of asphyxia. Delivery through meconium stained amniotic fluid (MSAF) is common, reported in 8-25% of births at >34 weeks, but the vast majority do not get MAS as there is no significant accompanying asphyxia. (1) The incidence of MAS has decreased over time as a result of fewer babies being delivered post term. (2) The presence of meconium stained amniotic fluid is a common reason for the paediatric teams to be called to attend deliveries, and the initial assessment of severity of this condition depends upon identifying whether there is evidence of coexisting asphyxia. Prompt clinical management and communication between the obstetric and neonatal team is essential in securing a good outcome.
- Supraventricular tachycardia in children
Tachycardia is a common observation in children which can represent many different physiological and pathophysiological conditions. Identification of cardiac arrhythmias as the cause of tachycardia can be difficult. This case-based discussion aims to illustrate the factors within history, examination, and clinical investigations which can lead the Foundation Year doctor to consider arrhythmia in their differential diagnosis. In addition, this article outlines evidence-based management of the most common clinically significant arrhythmia presenting in paediatric patients - supraventricular tachycardia.
- A 4-year-old boy with sickle cell disease & acute chest syndrome
A 4 year old boy with sickle cell disease (SCD) presented with abdominal and leg pain to his local district general hospital (DGH). He was treated for a presumed vaso-occlusive crisis (VOC) receiving antibiotics, fluids and analgesia. During the fist 24 hours, he rapidly deteriorated with respiratory distress, increasing oxygen requirement and left lower lobe consolidation on chest X-ray (CXR). He was intubated, ventilated and retrieved by PICU with a working diagnosis of acute chest syndrome (ACS). Multi-organ dysfunction syndrome (MODS) ensued over the subsequent 24 hours. He required high frequency oscillation ventilation (HFOV), inhaled nitric oxide (iNO), inotropes, and broad-spectrum antibiotic cover. Exchange transfusion decreased his HbS fraction from 45% to 15%. Over the next 12 days he required mechanical ventilation, inotropic support, haemofitration, antibiotics and antifungal treatment. Ongoing consolidation of one lung prompted a bronchoscopy revealing plastic bronchitis. Rigid bronchoscopy with instillation of DNAse and saline was required to remove the plastic casts. He was extubated two days later making a swift recovery thereafter. This article discusses the management of a child with SCD with reference to the current literature. Important aspects include the recognition, rapid progression, clinical management and outcome of ACS. Our discussion highlights the pitfalls of managing an unusual complication of ACS and the complexities of the decision making process.
- Febrile seizure
A previously healthy 2 year old boy, born at term, presented to the Emergency Department with his concerned parents. They described an episode at home that morning which had lasted three minutes in total, where he went flppy and stiff and thrashed his arms and legs around. On arrival to the department he was no longer fitting; his temperature was found to be 39.2°C. He was examined and observed in the department where he was found to have a sore, red throat. He had no further seizures and was discharged home that afternoon with no follow-up.
- Look before you leap: viral infections
Viral infections are the most common paediatric illnesses that you will encounter when working as the front line medical staff in any medical facility. Respiratory viruses are the predominant agents in this category. Even though these infections dominate paediatric illnesses, the mortality associated with this group of organisms is very low. It is also challenging to differentiate them from other serious medical conditions when children present with almost similar symptoms and signs. In this article we will look at a very common clinical presentation both in GP practice and in the acute paediatric service. Progressive disclosure of information is given in this case and so you are encouraged to select your answers as you go and not at the end of the case history.
- Prescribing in eczema
A 10-month-old girl was referred to our department with an itchy, erythematous eruption. It started at 8 weeks of age and episodes of exacerbation and remission were observed. Her parents reported that her skin had been worse over the winter. There was a family history of asthma. On examination she had a symmetrical, erythematous, scaly, weepy eruption affecting her cheeks, neck, ankles, knee and elbow flexures.
- Childhood epilepsy
Cherie, a 7-year-old girl, has been referred to paediatric outpatients following four “fitsâ€. The GP letter states on each occasion Cherie has “had jerking of her arms and legs, lasting 3–4 minutesâ€. Cherie is otherwise well, with no significant past medical history and normal development.
- Common paediatric orthopaedic conditions
An 8-year-old boy presents with a painful right elbow following a fall from a swing onto an outstretched hand. The child is not known to be on the child protection register and is otherwise fit and well. On examination there is extensive swelling around the elbow. The child is reluctant to let you examine the elbow due to the pain, yet the radial and ulnar arteries are found to be present but weak, with a increased capillary refill time of 4 seconds. The child is neurologically intact distal to the injury. A lateral X-ray of the right elbow shows a “fat pad sign†on the lateral view and a visible fracture in the distal humerus with a distal fragment partially tilted and displaced posteriorly. It is not possible to get an anteroposterior (AP) view due to pain. In children under 10 years old, fractures of the elbow are the fourth most common fractures, and the second most common long bone fractures, second only to fractures of the distal radius and ulnar in their incidence. The majority of these injuries are supracondylar fractures, with a peak incidence in children 6–8 years old. The most common cause of injury is for the child to fall onto an outstretched hand and the elbow to be forced into either a valgus or varus direction.
- Non-accidental injuries in children
Non-accidental injuries (NAI) are not uncommon in children and can present in many different clinical settings. Although the majority of children with suspected child abuse are referred to paediatricians with skills in child protection, many children with possible NAI may present to other specialties such as general practice, accident and emergency, orthopaedics, general surgery, psychiatry as well as to dental practices.
- Absent red reflex in a newborn
An absent red reflex in a neonate is a sign detected by paediatricians and General Practitioners at newborn baby checks. The failure of light to pass through the eye has serious implications for the development of neuronal connections between the eye and the brain. We present a case that exemplifies a typical history and management of this sign.
- Beware of Addison's Disease
We describe a girl with known Type 1 Diabetes Mellitus who had multiple presentations to the paediatric department before that "unforgiving master of non-specificity and disguise" (1), Addison's disease, was identified. The diagnosis was delayed and we present this case to highlight the difficulties in diagnosing Addison's disease in the context of commoner comorbidities.
- Investigating a neonate with failure to thrive
A 19 day old baby presented with excessive weight loss after birth, the initial cause of which was unclear. This article will provide a systematic approach to excessive weight loss after birth and faltering growth in infancy. No consensus exists on the definition of faltering growth and it’s duration. Weight gain less than expected for age (26-31 g/day between 0-3 months and 9-18 grams between 3-12 months) is one of the parameters used. History, examination and investigations will be explored to form a differential diagnosis and make a diagnosis.
- Unexplained seizures in an infant
We present a case of a 4-month old female who presents with a history of a seizure following a feed. This article reviews the role of the junior doctor in the investigation of non-accidental injury, including obtaining a relevant history and carrying out a thorough examination. The imaging protocols issued by The Royal College of Radiologists and The Royal College of Paediatrics and Child Health are summarized. The specificity and mechanism of injuries are also discussed.
- Septic arthritis of the paediatric hip
We present a case of a 12-year-old girl with a 2-day history of pain in her right hip. Key elements in her history and examination reveal the cardinal features of septic arthritis and are then confirmed on further investigation. Paediatric hip pain is very common and has many different causes. One of the most concerning and significant causes is septic arthritis. Diagnosis of this disorder can be difficult. Our aim in this case based review article is to describe the management by example. We recommend using a scoring system to decide which children are most at risk of septic arthritis, in order to guide initial management. We also describe the surgical treatment for septic arthritis of the hip, once the diagnosis has been made.
- Manifesting carrier for Becker Muscle dystrophy
This is a case summary based on an adolescent presenting at the age of 10 years with an inherited neuromuscular disease manifesting as scoliosis. The report highlights her clinical history, examination, investigations, complications and multidisciplinary management. It emphasises a holistic family-centred approach to care of chronic paediatric disabilities.
- The pigmented skin lesion: the role of biopsy in dermatology
Diagnostic skin biopsies play an essential role in dermatology and provide information that can be correlated with the clinical impression to give a diagnosis. We discuss the presentation and management of two patients with pigmented skin lesions in order to highlight some important principles of skin biopsy. The biopsy strategies varied in each case due to the clinical impression, the size and site of the lesion. Excisional biopsy is the method of choice for clinically suspicious lesions. Other methods such as incisional biopsy, punch biopsy or curettage may be used for benign or pre-malignant lesions depending on lesion characteristics and patient preference.
- Generalised skin rash
A generalised skin rash progressing to full thickness skin necrosis is described in a 71-year-old male presenting with upper gastrointestinal bleeding in the presence of alcoholic liver disease. The clinical diagnosis, role of investigations and management are discussed. An infective aetiology is postulated for the rash.
- Neonatal resuscitation and intensive care
Neonatal resuscitation and intensive care is based on a systematic approach. In this article, an atypical case of neonatal respiratory distress highlights fundamental transferable lessons applicable to all foundation trainees. Although neonatology is a complex speciality, knowledge of the key differences between adults and neonates will help to reinforce resuscitation principals and the important points of clinical assessment. An increased focus on respiratory distress and causes of neonatal sepsis, will allow juniors to manage many problems effectively. Finally, in paediatrics it is of increased importance to consider and involve the family.
- Undescended testes
Undescended testis is a common indication for referral to paediatric surgery. Its surgical management is guided by clinical examination findings. We present a case based discussion encompassing the aetiology, presentation, surgical management and outcome of an undescended testis.
- Hemolytic uremic syndrome (HUS) in children
This case-based discussion is based on an 8-year-old girl who presented with haemolytic uraemic syndrome (HUS) characterised by the triad of thrombocytopenia, micro-angiopathic hemolytic anaemia and acute renal failure, following a diarrhoeal illness caused by escherichia coli O157:H7. The case will highlight relevant aspects of clinical history, physical examination, laboratory investigations, pathophysiology, complications, prognosis, disease notification, management and follow-up of children presenting with HUS. The most common cause of HUS is systemic uptake of toxins in 5–10% of individuals infected by Shiga-like toxin-producing E. coli (STEC). Other infective agents such as pneumococci and HIV, complement genetic abnormalities, medications, transplantation, malignancy or autoimmune diseases are responsible for 10% of cases of HUS, referred to as atypical or D-HUS.
- A youngster with a swollen eye
This 6-year-old boy presented 24 hours earlier to A&E department complaining of a swelling of the right eye. He was assessed by a Casualty officer and given oral antibiotics for presumed peri-orbital cellulitis. His parents returned to A&E the following day as the swelling had progressed and he was unable to open his right eye. On examination there was no evidence of discharge or trauma. The boy's mum indicated that he had only a minimally ''runny'' nose. He had a mild pyrexia.
- A challenging case of deliberate self harm/self injury in the young adolescent
This article gives a brief history of a deliberate self harm/self injury case in 2 young girls followed by a discussion about the management of the patients. Within the discussion a number of important factors will be briefly discussed including Gillick competence, capacity, confidentiality, child protection and the Acts that encompass all these issues (i.e. Mental Health Act, Mental Capacity Act and the Children Act). The reader is advised to refer to Trust and Local or National policies for further information.
- Benign epileptic syndromes of childhood
Benign epilepsies refer to a group of epilepsies in which remission and lack of significant neurologic sequelae is expected in the majority of patients. These disorders are idiopathic, occur in otherwise healthy children, and usually have strong genetic links. They include generalized and focal onset epilepsies. In this article we have presented the childhood benign epilepsies according to the age of onset, starting from the neonatal period.
- Childhood limp: a delayed presentation
A case of delayed presentation of an important cause of painless limp in a 14-month-old child is described. The differential diagnosis is mentioned, and risk factors for the condition are discussed.
- Sickle ß thalassemia and secondary prevention of stroke
A girl with Sickle ß Thalassemia was started on a long term transfusion programme after suffering from a stroke at the age of 7. This involves regular blood transfusions, with the aim of keeping the percentage of sickle haemoglobin (HbS%) as low as possible, ideally below 30, to reduce the risk of further strokes. Despite a combination of top up transfusions and exchange transfusions, which have allowed some control of the patient's HbS%, ischaemic changes and vascular abnormalities in her brain have deteriorated. She now awaits a stem cell transplantation. Previous international trials have demonstrated that children who have had an infarctive stroke have high risk of having a further stroke if they remain untreated. This risk can be signifiantly reduced if children are established on the transfusion programme. The transfusion programme can only be effective if the HbS% is adequately controlled, which can be difficult, as is seen in our patient. Stem cell transplantation (matched sibling donor/haploidentical) is potentially curative and offers the option for definitive secondary prevention of strokes, but is a toxic procedure and currently reserved for patients with a severe clinical course.
- Evaluation of a child with fever & rash - the logical approach
The case describes the approach to the evaluation and management of an infant who is admitted with fever and rash. There is progressive disclosure of information and scheme of investigations and management as the case progresses. Ideally, decisions have to be made at each point with the information given and once more information has been obtained, you are not allowed to go back and modify your previous decision, which is what happens in real life. The discussion that follows the case description is a 'think aloud' of an experienced clinician, backed up with evidences from literature search.
- Pain control in palliative care
Peter is a 62-year-old man who has recently been diagnosed with locally invasive prostate cancer. He comes to see you complaining of pelvic pain. It is somewhat relieved by paracetamol, but is waking him up at night. What would you prescribe?
- End-stage respiratory disease: managing distressing symptoms
Respiratory disease is a major cause of mortality in the UK. The symptom burden is often underestimated and is comparable to the symptoms of malignant disease. End stage respiratory disease is often marked by a slow, relentless decline with prolonged periods of disability secondary to dyspnoea, reduced exercise tolerance and multiple hospital admissions. The main symptom encountered is breathlessness which can be challenging to manage. The following article describes the issues faced by a patient suffering from end stage chronic obstructive pulmonary disease and offers guidance for the management of distressing symptoms.
- Food and fluid at the end of life
In some patients, artificial nutrition and hydration (ANH) can improve general well-being and prolong life (1). However, in patients with a life-limiting illness, ANH could potentially prolong suffering. In dying patients, the burden of ANH can often outweigh any medical benefits. This article uses a case to illustrate some of the clinical considerations around ANH at the end of life and reviews the available evidence. In the context of this article "end of life" refers to the last days of life.
- The management of malignant pleural effusions
This article examines the assessment and management strategy of patients with a malignant pleural effusion with the aid of an illustrative case history.
- Care of the dying patient in hospital
Around half a million people die in England each year and 58% of these deaths occur in the hospital setting. Almost two-thirds of these deaths occur in people aged over 75 and follow a period of chronic illness, e.g. heart disease, cancer, stroke, chronic respiratory disease and dementia (1). However, despite the large number of dying patients that we care for in hospital, evidence suggests that we provide suboptimal care (2,3). This is also reflected by the high number of complaints received by the Healthcare Commission involving issues around death4. Over the last two decades, the relatively new speciality of Palliative Care has emerged with the aim of providing advice and guidance on the medical management of symptoms at the end of life closely linked to a much more holistic approach of providing emotional, social and spiritual support for patients and their carers. The important role of palliative care is also covered in the undergraduate and Foundation programme curricula (in particular, communication skills, breaking bad news, and skills and knowledge supporting DNAR orders and advance directives).
- Vaccinations in the elderly
This case report reviews the role of vaccination in protecting the elderly, who are at particular risk from infections including influenza and pneumonia and their associated complications. The availability, indication and context of appropriate vaccination are discussed.
- Detrusor instability
This case based discussion focuses on an independent, community-dwelling 84-year-old lady presenting with urinary incontinence and discusses the assessment, differential diagnosis and treatment of urge incontinence due to detrusor instability.
- Rehabilitation in a cognitively impaired patient
Mrs EW, an 84-year-old woman, was admitted to the Emergency Department after being found on the floor by her home help. The patient had a past history of dementia and was at risk of falls. After initial management and investigation for possible causes of falls the patient wanted to go home. There were concerns raised about her safety by her daughter who wanted her mother to be admitted to a residential home. The focus of this case based discussion is on rehabilitation in patients with cognitive impairment and discharge planning.
- Postnatal depression
Mrs M is a 32 year old in hospital following the birth of her third child. She delivered three weeks ago. The delivery was a difficult one and her child is currently on the Special Care Baby Unit. Although her child is progressing well, for the last two weeks Mrs M has been tearful, not engaging well with her child when she visits, looks dishevelled, and is convinced her baby will die despite reassurances from members of your team. You are the FY doctor looking after Mrs M’s child – what do you do?
- Management of first-episode psychosis in a young person
An eighteen year-old man presented in a distressed and agitated state, having been brought to the Accident and Emergency Department by his concerned mother. His mother explained that until a few months ago her son had been his usual self, enjoying a college course and socialising with friends. After this time he gradually became increasingly reclusive, withdrawn and depressed. Over the preceding two weeks his behaviour had become bizarre and she had overheard him talking and “arguing†with himself in his bedroom. He also took to wrapping electrical items with kitchen foil and would only leave the house wearing sunglasses and a heavy coat. On examination the young man presented as anxious, distracted and preoccupied. Generally his mood appeared low, although at times he smiled or laughed for no apparent reason. He specifially denied hearing “voices†but admitted he was frightened and felt he was in great danger. When asked about suicidal thoughts he said he had been thinking of “ending it all†to prevent “something worse†happening to him.
- Depression
RS is a 28 year old woman who has come to your GP practice with concerns about poor sleep and reduced appetite for the past month. She works as a copywriter for an advertising agency and is having relationship difficulties with her partner. She has noticed that she struggles to concentrate at work and frequently finds herself crying at the smallest provocation.
- Benzodiazepines and Z drugs: managing inappropriate hypnotic prescribing in clinical practice
Inappropriate hypnotic prescribing is quiet common in clinical practice and is a widespread problem. This may lead to difficulty in withdrawing the drug if the patient has taken it for more than a few weeks. The use of hypnotics is associated with the development of tolerance, dependence and withdrawal symptoms.
- Charles Bonnet syndrome
We describe a case of visual hallucinations in a man with visual impairment, a common phenomenon that is often under-recognised.
- Obsessive-compulsive disorder
A case is described of a patient suffering with obsessive-compulsive disorder (OCD), and the obstacles she has faced in different areas of her life due to stigmatisation. The article also describes circumstances where she was shown quite the reverse: empathy and support. Stigma, discrimination and the outcome for this patient are then discussed.
- Electroconvulsive therapy
First used in 1938, ECT remains the most effective form of treatment for a minority of severely depressed patients, for whom it may be a life-saving intervention. Foundation Year Doctors should be familiar with the treatment, including the likely benefits and risks associated with ECT. In this article, the authors describe the practical aspects of the procedure and clinical scenarios where it might be used.
- Assessing mental capacity
A person's capacity to make decisions can be affected by many medical conditions. Some have permanent or long-term effects, while others have only a short-term or intermittent effect. Examples include a stroke, dementia, a learning disability or a mental illness.
- Assessment and management of frontal lobe impairment on a general hospital ward
Frontal lobe impairment can occur as a result of a number of different illnesses, or following trauma. Often, impairment first manifests as a change in a patient's behaviour or personality. This can cause distress for both the patient and their relatives. We describe the case of a man with frontal lobe dysfunction whose behaviour posed challenges for his management on a medical ward.
- The case of a patient suffering from mixed anxiety and depression
David is a 64 years old retired engineer. He lives with his wife. They live alone and have a son who lives away from them. David was unfortunately diagnosed with Parkinson's disease in early 2009. He initially approached his general practitioner just after Christmas 2008 because of symptoms of feeling anxious and experiencing tremors of hand. He was treated for anxiety at the time. However, as the symptoms did not improve he was further investigated. Only then it became apparent that David was suffering from Parkinson's disease. A few months after starting his anti parkinsonian medication, he started feeling low in mood and found it difficult to sleep. He also found it difficult to concentrate and avoided going out, especially to public places. He used to enjoy hobbies such as gardening, but now he didn't feel like doing that anymore. As David and his wife were concerned about his mental health they asked to see their general practitioner.
- Capacity: everyone's business
In an evolving complex healthcare system, assessment of capacity is increasingly becoming central and paramount in everyday clinical practice and is a core competency for foundation year doctors. Capacity is a legal concept. Given the fact that in general and psychiatric hospitals around 30% of patients may lack capacity, it is everyone's business, in everyday clinical practice to keep themselves abreast with the challenges and complexities involved in the assessment of capacity.
- Catatonic syndrome
A case will be presented of a first episode of psychosis with features of catatonic syndrome. Diagnostic challenges are discussed and some potential pitfalls in treatment are detailed. A brief discussion about these matters follows with reference to some current ideas around the diagnosis, treatment and classification of catatonic syndrome.
- A case of depression
Depression is a common mental illness and presents in primary and secondary care settings. This article is a case based discussion about David, a 42 years old man who presented with depressive symptoms. It explains the clinical assessment and management of depression. The identification of physical illness which can co-exist with depression is essential. Treatment should include pharmacological, psychological therapies and offering adequate support in crisis situations. Sufferers of depression are at increased risk of committing suicide and the risk rises to 20 times in the most severely ill. The importance of risk assessment is highlighted. If management options fail, then 'treatment resistance' needs to be considered.
- Introduction to alcohol use disorders and treatment of alcohol dependence
The presentation of alcohol and drug misuse is not limited to a particular psychiatric or medical speciality. Alcohol and drugs play an important part in all aspects of psychiatric practice. This article looks at the different types of alcohol use disorders, how to assess people with such disorders (with the aid of validated assessment tools) and the appropriate treatment pathway recommended by recent NICE guidelines. Information on pharmacological interventions available during the process of detoxification and relapse-prevention is also available. This has been done with a case example to help apply theory and guidelines to clinical practice.
- Neuropsychiatry of brain injury
Cases of brain injury can be subtle yet have lasting and very disabling psychiatric consequences including depression, post traumatic stress disorder, panic attacks and cognitive impairment interacting deleteriously with physical effects. We present a case and discuss important points for assessment and treatment in practice. This article is published with the patient's consent.
- The Mental Health Act 1983
A 23-year-old man, CW, is brought to A&E by two police officers. The police were called because he was shouting at people in the street. When approached by the police he told them that he had recently taken an overdose of paracetamol. They decided to bring him to hospital and chose the general rather than psychiatric hospital because he had taken an overdose.
- Panic and agoraphobia
One evening in A&E you are asked to see a 19-year-old Caucasian woman, Lorraine, who presents with palpitation, breathlessness and numbness in her fingers. It is impossible to obtain any history from her as she is extremely distressed and agitated. On examination, her BP is 140/95 with a pulse rate of 102. Her respiratory rate is 28/minute and she is apyrexial with a temperature of 36.2. Her chest is clear on auscultation, she has a normal peak flow and capillary oxygen saturation and her heart sounds are normal. Examination of her nervous system reveals no abnormality. There is no palpable thyroid and no bruit. You suspect that this may be psychogenic in origin but first ask the casualty officer for her opinion. She confirms your findings and asks you to obtain a blood sugar reading but if this is normal to try and calm her down and obtain a history of the presenting complaint.
- Delirium
Three hospital inpatients are referred with very similar presentations. Each has become agitated and distressed, disturbing other patients and causing concern for staff.
- Munchausen's syndrome (factitious disorder)
Munchausen's syndrome is a condition characterised by deliberately produced plausible symptoms and often signs of illness, presented for the sole purpose of assuming the sick role and gaining admission to hospital (1).
- Factitious disorder
"Factitious disorder refers to the conditions consisting of intentional production or feigning of signs of medical or mental disorder along with misrepresentation of history and symptoms in order to assume the sick role without any external incentive" (1).
- Electro-convulsive therapy: does it have a role in the management of depression?
A 75-year-old woman, called Mrs K, is brought to the A&E by her daughter. She has not been eating properly for some time and has lost a considerable amount of weight as a result. Mrs K takes a long time to answer questions and talks in a quiet voice. She says to the Casualty Officer that there is no point in eating because she is empty and hollow inside, and would not be able to digest the food. In any case, she adds, she is tired of life and would like to die; she feels she is a burden to her daughter and does not deserve to be looked after. In fact, she has been considering the possibility of taking an overdose of tablets in order to finish it all. Mrs K has been hearing a voice telling her that she is a wicked person and that she is going to be taken to prison. Her daughter explains that Mrs K has a previous history of depression and is on antidepressant medication: she had been on amitriptyline for a long time, but this was changed to sertraline a few weeks ago, when she started to develop her current symptoms. Her mood deteriorated after she received a letter from the council, threatening her with court action for non-payment of council tax, for which she was, in fact, exempt. Mrs K is generally independent, despite her belief that she is a burden to her daughter. She also takes medication for her blood pressure, as well as a laxative.
- Triple jeopardy in a person with Fragile X syndrome: how to address stigma
Throughout history, people with learning disability have been labelled, and subsequently suffered from poor treatment and abuse. We describe a case of a twenty year old Afro-Caribbean gentleman who has learning disability, Fragile X syndrome with dysmorphic features and a history of mental illness (triple jeopardy). His experience of stigma and subsequent discrimination resulted in him suffering bullying and social rejection. The magnitude of this kind of stigma poses a particular challenge for the development of interventions that will make a real difference to the discrimination and social exclusion experienced by people with mental illness and learning disability. Unfortunately, there have been reports that anti-stigma campaigns are not particularly effective. This is noted in the constant search for de-stigmatising terminology. More effective strategies are reported, backed up by legal and regulatory frameworks, thereby changing attitudes, respecting rights and promoting independence, access and choice of individuals with learning disability, as social inclusion becomes the norm.
- A painful acetabular metastasis treated with CT guided coblation & cementoplasty
A 66 year old man was referred by the GP, to the dermatology clinic under the two week wait with a suspicious dysplastic mole on his upper chest. This was excised in August 2011 and histology demonstrated a superficial spreading malignant melanoma. The histology was discussed at the skin cancer MDT and it was decided that he required a staging CT, and wide local excision with a sentinel lymph node biopsy.
- CT coronary angiography
This article will focus on CT coronary angiography (CTCA), a commonly performed non-invasive cardiac imaging test. We present three case based discussions to explain the indications, contraindications, advantages of CTCA and its relevance in patient management.
- Findings in appendicitis
We present an interesting case of acute appendicitis encountered during a surgical on-call. This case based discussion focuses on the appropriate investigation of appendicitis as well as imaging findings of alternative differential diagnoses.
- Diagnosis and management of rheumatoid arthritis
We discuss a clinical case of a 51-year old woman who presents to the rheumatology clinic with foot pain and swelling, by means of which we will overview all imaging modalities available to diagnose and manage patients with rheumatoid arthritis.
- Interpretation of the chest X-ray in patients presenting with chest pain
The chest x-ray is the most frequently requested imaging examination with chest pain as one of the most frequent indications, but it is one of the most difficult to interpret. The importance of a strategy for interpreting the chest x-ray findings of adult patients presenting with ‘chest pain’ is highlighted by the two cases presented. The reporting radiologist often does not have the benefit of any additional information to tailor the diagnosis. Viewing the image with an open mind can be advantageous, preventing too narrow a focus on a single area with the potential to miss significant findings. However additional clinical information on the imaging request can improve the reporting radiologist’s understanding of the clinical context, enhance the quality of the report and thus impact on patient care.
- The role of magnetic resonance angiography
Magnetic Resonance angiography (MRA) is increasingly used in place of intraarterial catheterisation for imaging the vascular system. The main benefits are the absence of ionising radiation, avoidance of arterial puncture and its associated complications, and ability to perform angiography without iodinated contrast agents.
- Unexplained seizures in an infant
We present a case of a 4-month old female who presents with a history of a seizure following a feed. This article reviews the role of the junior doctor in the investigation of non-accidental injury, including obtaining a relevant history and carrying out a thorough examination. The imaging protocols issued by The Royal College of Radiologists and The Royal College of Paediatrics and Child Health are summarized. The specificity and mechanism of injuries are also discussed.
- Orthopaedic radiology cases
A 27 year old man presents to A&E following a motor vehicle accident. He complains of severe pain and swelling in the right knee, and is unable to weight bear. On examination, his knee is tender, swollen and has severely restricted range of movement. There are no visible wounds around the knee. Antero-posterior and lateral view radiographs of the right knee are performed.
- Diagnosis and management of strokes in teenagers and young adults
Although much more common in older adults, stroke should also be included in the differential diagnosis of acute focal neurological deficit presentations in young adults, teenagers and children, although it remains a rare presentation, with an incidence of ~1:20.000. In older adults atherosclerosis is the most common cause but in younger patients this aetiology is uncommon and other causes have to be considered. This case-based discussion will focus on patient presentation and physical examination findings, with guidance into appropriate management and radiological imaging. The classic findings in different imaging modalities will be briefly explained.
- Recognising bone tumours on imaging: common cases of benign and malignant bone lesions
Bone tumour often presents with non specific symptoms and is frequently discovered on imaging as an incidental finding. As there are bewildering number of benign and malignant bone tumours, brief knowledge of various radiological signs which differentiate aggressive and non-aggressive bony lesions would help to narrow the differential diagnosis to help early diagnosis. This can improve the patient outcome dramatically. Patient age remains one of the most important clinical factors in the diagnosis of bone tumours, because certain tumours have predilection for specific age groups. The approach to the radiographic diagnosis of bone tumours should start in a systematic way with attention to the specific radiographic features of tumour location, margin, zone of transition, periosteal reaction, mineralisation, size and number of lesions and presence of a soft-tissue component. We aim to provide brief overview of some of the commonly occurring benign and malignant bone lesions in this case based discussion.
- X-ray interpretation of 10 common adult fractures
Two radiologists have put together a short tour through 10 most commonly encountered in adults fractures. The cases have been chosen for their frequency, importance of prompt diagnosis and typical clinical presentations aiding pattern recognition. Salient features have been presented as bullet points for a quick reference. Common pitfalls to avoid have been stressed.
- Plain film interpretation of traumatic elbow injuries in children
Elbow fractures are common injuries in children, however evaluating radiographs of the paediatric elbow can be challenging. Difficulties in analysis result from both the complex nature of changing anatomy in the developing child and the subtle radiographic findings associated with serious fractures.
- Acute headache and aneurysmal bleed: a potentially life threatening stroke
Acute headache is a common presentation to the emergency department. The aetiology of acute headache is wide and varied which can pose a challenge to establish clinical diagnosis and plan further management. Subarachnoid haemorrhage (SAH) is one of the important causes of acute headache that could be life threatening. The cause of SAH is a ruptured aneurysm in 85% of cases (1), nonaneurysmal perimesencephalic haemorrhage in 10%, and a variety of rare conditions in 5%. Recognising the presentation of SAH and prompt imaging helps in establishing the diagnosis and subsequent management. In this case based article we will discuss the clinical presentation, imaging findings and management of aneurysmal bleed, the most common cause of SAH.
- Common cases of arthritis
Arthritis is a pathophysiologic process affecting the joints and can present with various symptoms and signs. Often plain radiograph is the first investigation of choice and it can help in early diagnosis and management. Though each disease has it's own hallmarks, sometimes there can be more than one process involved making the diagnosis difficult. Also, to the untrained eyes, all arthritic radiographs may look the same and are often confusing. This review article, with case based discussion, will provide you with stimulating knowledge of the most common arthritis that will help you identify them and give you the ability to narrow down the differential diagnosis in degenerative or inflammatory disease to begin with.
- Imaging characteristics of common acute abdominal conditions
Acute abdominal pain accounts for 5-10% of visits to the emergency department, and imaging plays an important role in the management of these patients, especially as clinical evaluation results can be inaccurate. CT can provide accurate and reproducible diagnosis. Imaging has been shown to have a positive effect on the accuracy of the clinical diagnosis (1,2) to lead to changes in management decisions (3,4) and to increase the level of diagnostic certainty in patients with acute abdominal pains (5,6). It is with this in mind that we would like to illustrate the important imaging characteristics, on CT, of common acute abdominal conditions presenting to the Emergency Department.
- Tubes and lines in radiographs
Plain radiography is integral in the examination of ill patients particularly nursed in intensive care and high dependency units. Evaluation of placement of tubes and lines is critical to ensure patient safety before administration of treatment. Immediate help from radiologists will not be always be available, hence junior doctors should be competent to evaluate these radiographs for this crucial information. The purpose of this pictorial review is to discuss the expected range of normal position of the commonly used devices and illustrate their abnormal placement. For the purpose of simplicity, we will be discussing central venous catheters; endotracheal tube and nasogastric tube which constitute the most commonly placed tubes and lines in acute setting. Other tubes like pulmonary artery (swan-ganz) catheters, intra-aortic balloon pumps, umbilical artery/vein lines, pacing wires will not be covered in this article.
- The radiology of shoulder dislocations
A 23-year-old man presents to the Emergency Department with a severely painful right shoulder having fallen awkwardly during a judo match. Clinical examination reveals an obvious deformity to the right shoulder and an inability to move the right arm without precipitating severe pain. There is no evidence of neurovascular injury in the arm. A shoulder dislocation is suspected.
- Management of pleural effusion
A 67-year-old retired electrician presents to the medical admissions unit with a 6 week history of progressive breathlessness and weight loss. He was previously fit and well and on no regular medication. He stopped smoking 20 cigarettes a day 30 years ago, having started smoking in his teens and had exposure to asbestos whilst working on building sites in his 30s.
- The breathless patient
You are the Foundation Year 1 covering the wards on an evening on-call. You are bleeped by the nursing staff on one of the general medical wards who would like you to come and see a patient they have become concerned about. They tell you on the phone that the patient, who was previously well, is now breathless and that their saturations are 78% on air.
- Prescription of long-term oxygen therapy
Mr Smith is a 78-year-old man admitted to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD). He is known to have moderately severe COPD with a 50 pack year smoking history; and his usual treatment was Symbicort and tiotropium inhalers. The exacerbation settles with appropriate standard medical management and he is ready to be discharged. Throughout his admission he has required oxygen therapy and is still using it. He raises the question that his GP has mentioned the possibility of having oxygen at home and asks if this can be arranged.
- A new presentation of HIV and PCP
A 51-year-old married man was admitted to the medical admissions unit with a four-week history of progressive shortness of breath and a non-productive cough. He also reported generalised lethargy and 2 stone weight loss over the previous six months. He had no past medical history and was a smoker of 20 pack-years.
- Respiratory arrest: a case for urgent treatment
A 22-year-old previously fit male was brought to the emergency department in respiratory arrest. Earlier on the same day, he had developed progressively increasing shortness of breath. He was administered nebulised salbutamol by paramedics en route to hospital, but rapidly became apnoeic and had a seizure on the way to hospital.
- A patient with diffuse lung disease
A 68-year-old man presented with a one-week history of progressive breathlessness with effort intolerance and orthopnoea. For the preceding five months he had also noted dysphagia to solids. He had a 20 pack-year smoking history, and a history of ischaemic heart disease. On admission he was in moderate respiratory distress, hypoxic and apyrexial. Chest examination revealed bilateral crackles with a mild expiratory wheeze and dullness to percussion at the right lung base. The remainder of the examination was normal.
- Chronic cough
A 67 year old, who had never smoked, presented with a productive cough for 6 months, and then developed features of pneumonia which persisted for a further 2 months despite antibiotics. A CT scan revealed an endobronchial dense opacity in the right main bronchus (Figure 1). Bronchoscopy identified a chicken bone wedged across the intermediate bronchus (Figure 2), which was successfully removed with forceps. In retrospect, the bone is visible on his initial chest x-ray (CXR) adjacent to the right heart border (Figure 3, arrow).
- A community-acquired pneumonia in a patient with chronic lung disease requiring intensive care (level 3) admission
We report a case of community-acquired pneumonia in a 73-year-old Caucasian lady with a background history of chronic airways disease (COPD) who was admitted in a state of septic shock and a CURB-651 score of 5 which needed level 3 (ITU) treatment and mechanical ventilation. Clinical examination and X-ray findings suggested bilateral consolidation complicated by a pleural effusion. Sputum and broncho-alveolar lavage (BAL) cultures grew Streptococcus pneumoniae and Enterobacter cloacae. She failed to respond to initial empirical antimicrobial treatment with co-amoxyclav and clarythromycin but responded well to meropenem.
- Invasive and non-invasive ventilation
Respiratory failure is one the commonest medical emergencies. Many patients improve with standard medical therapy but some need respiratory support with non-invasive or invasive mechanical ventilation. Bi-level non-invasive ventilation (NIV) is effective if used correctly for type 2 respiratory failure due to the exacerbations of chronic obstructive pulmonary disease but can be dangerous if used inappropriately. The use of NIV in other conditions such as pulmonary oedema is less established. Some of the dangers of NIV can be reduced by appropriate prior consideration of a plan in case NIV fails. Invasive ventilation is another option which protects against some of the problems of NIV but has its own complications. In this article we discuss these issues with reference to two illustrative cases.
- Interstitial lung diseases
Interstitial lung diseases (ILD) describes a large group of disorders of lung interstitium. Whilst the majority of patients with ILD present with breathlessness and cough, these disorders may have multi-system involvement. Patients with ILD can be seen on acute medical take or on medical or surgical wards, and therefore understanding of ILD is of importance to junior doctors. The terminology, investigations and treatment of ILD can be perceived as somewhat complicated. This article will provide a simple approach on how to assess, investigate and manage patients with ILD. More importantly, the requirements of careful diagnosis will be highlighted as this may affect not only the management options but also has important role in establishing the long term prognosis. The diagnosis of ILD frequently requires a multi-disciplinary approach, which involves a close communication between respiratory physicians, radiologists, histopathologists and thoracic surgeons. Some of the ILD can be confidently diagnosed based on clinical history, examination and radiological appearances of high resolution computed tomography of the thorax. However, in many cases further investigations including surgical lung biopsy may be required. The management usually depends on the type or severity of ILD.
- Chronic obstructive pulmonary disease: aiming for a good outcome.
The aim of this case history is to highlight some of the current issues around assessing and treating a patient with an acute exacerbation of COPD. It details the presentation to hospital of a 78 year-old woman with severe COPD during her final acute exacerbation. She had once again presented to the accident and emergency department significantly short of breath despite the use of her home oxygen. In spite of thorough assessment, investigation and appropriate management, she did not survive. Treatment was rapidly administered and NIV was used in an attempt to correct an acute respiratory acidosis which had developed on a background of chronic respiratory failure secondary to COPD, with ensuing cor pulmonale. Appropriate decisions were made early about the ceiling of care and despite maximal therapy the patient deteriorated. Once a diagnosis of dying was made the patient was managed accordingly to ensure that her death was not distressing. As a foundation year doctor when faced with complex cases such as this, with clinically very unwell patients who may not survive it is very important to seek help early.
- Palliative care in end-stage chronic lung disease
The prognosis for severe COPD is comparable to inoperable lung cancer but few patients dying from COPD receive adequate palliative and end of life care. Early identification of patients with poor prognostic features and a multi-disciplinary approach to treatment are required to optimise symptom control, quality of life and end of life care.
- Pneumonia in the immunosuppressed: a medical emergency
A sixty one year old female with no significant past medical history, underwent cadaveric renal transplantation for end stage renal failure secondary to adult polycystic kidney disease. Following transplantation she was treated with prednisolone and tacrolimus to prevent graft rejection and the perioperative period was uncomplicated. Subsequently she suffered from intermittent neutropaenia due to heavy immunosuppression and the acquisition of cytomegalovirus. This caused further marrow suppression and two episodes of CMV pneumonitis, treated with valganciclovir.
- Pulmonary vasculitis
Pulmonary vasculitis is rare but carries high risk of morbidity and mortality if not diagnosed and treated early. Its main symptoms of cough, haemoptysis and general malaise are not specific and are often attributed to more common diseases such as pneumonia. In this article we discuss a representative case and provide a general review of this condition.
- Management of acute type 2 respiratory failure
Acute type 2 (hypercapnic) respiratory failure is a potentially life-threatening complication that is more likely to develop in patients with certain underlying conditions. The morbidity and mortality from the consequent disturbance in acid-base balance can be significant. In hospital it can develop as the result of inappropriate oxygen therapy and is therefore often preventable. Awareness of those at risk and an understanding of the principles of oxygen therapy can prevent it from developing in many cases. Patients with type 2 respiratory failure may develop confusion, irritability and decreased consciousness although the diagnosis can only be made by arterial blood gas (ABG) interpretation. The precipitating cause can be determined by routine investigations, including chest X-ray and bloods tests. The immediate management includes treatment of the underlying cause, careful prescribing and monitoring of oxygen therapy (by serial ABGS) and the commencement of non-invasive positive-pressure ventilation (NIPPV), usually Bi-level Positive Airways Pressure (BiPAP), the use of which is supported by evidence from randomized controlled trials (RCTs) and included in national guidelines. Although NIPPV has significantly improved mortality and morbidity in patients with type 2 respiratory failure, there are contraindications. When BiPAP is contraindicated or not tolerated, respiratory stimulants can be administered. As many patients who develop type 2 respiratory failure have severe, chronic disease, there are ethical issues regarding escalation of treatment and invasive ventilation in the Intensive Care Unit (ICU).
- Functional and psychological aspects of breathlessness
Acute dyspnoea or breathlessness is one of the commonest presenting complaints to emergency or acute medical departments. The causes vary widely from respiratory to cardiac or haematological diseases. However, functional disorders often associated with anxiety or depression or other psychological diseases can present with breathlessness. This is not uncommon, but often not appropriately diagnosed and mistreated with harmful side-effects, due to general lack of recognition of this aspect of breathlessness. Some of the common presentations are the clinical entities of vocal cord dysfunction (VCD), hyperventilation syndrome (HVS) and dysfunctional breathing (DB). Any of these may present alone or as an epiphenomena to another disease such as refractory asthma. Awareness of foundation doctors of these conditions and what would be required to make diagnosis and arrange treatment plans is crucial to the initiation of proper management and the avoidance of harmful inappropriate interventions. In this article we present some illustrative cases and provide general tips to foundation doctor trainees on this subject.
- Disorders of the pleura
Diseases affecting the pleura represent challenges to both acute/general physicians and respiratory specialists alike. The presentation occurs in the young and old, the previously healthy and those with chronic illness. Pleural disease can reflect terminal illness or acute reversible pathology. Using a case based discussion approach this article looks at three common presentations of pleural disease; unilateral pleural effusion, pleural infection and pneumothorax.
- Pleural effusion: a rare but important cause
Mr GD, a 77 year old male retired pharmacist, presented to the Ulster Hospital Dundonald with cough and breathlessness of approximately four months' duration. He had previously been well. He was a lifelong non-smoker and had never been exposed to asbestos or tuberculosis. He denied fever, sputum, haemoptysis or weight loss. He had previously been well from a respiratory point of view. His past medical history included hypertension and duodenal ulceration.
- The obesity hypoventilation syndrome
Obesity is a rapidly increasing health problem. Obesity hypoventilation syndrome (OHS) is defined as the combination of obesity (BMI>30), awake hypercapnia (PaCO2 >6 KPa) accompanied by sleep disordered breathing. The condition is under diagnosed and under appreciated, and puts a significant burden on health care, prolonging length of hospital stay and an increased need for intensive care and mechanical ventilation. Interrelating mechanisms thought to cause OHS include respiratory load and mechanics, central respiratory drive, sleep disordered breathing and leptin resistance. In this review, we will discuss the definition, clinical presentation and diagnosis as well as differential diagnosis of OHS. We will summarise the epidemiology, review the current understanding of the pathophysiology and discuss the recent advances in treatment.
- Tuberculosis
A 26 year old woman presents to her GP on several occasions over a 3 month period with a dry cough and non-specific chest pains. She is given two courses of antibiotics, but has no improvement. Her GP sends for a CXR and the duty radiologist asks the medical team to review the patient. You review her on the AAU.
- Chemical pleurodesis: what is it and how to do it
Bedside medical pleurodesis is a procedure that is performed to prevent re-occurrence of pleural fluid. Medical pleurodesis is usually performed in the context of patients with recurrent pleural effusion due to underlying malignancy. The procedure involves instillation of an agent such as Talc into the pleural space. The aim of the procedure is to prevent pleural fluid from recurring by artificial obliteration of the pleural space through creation of an adhesion between the parietal and visceral pleura. The common complications of pleurodesis include pain, fever and occasionally potentially fatal respiratory failure due to pneumonitis or adult respiratory distress syndrome. It is important that the procedure and its complications are carefully explained to the patient and documented in the medical notes. Currently medical bedside pleurodesis carries a success rate of approximately 80%. Alternative procedures that allow for pleurodesis to be performed, which carry much higher rate of success but are also more invasive, include medical thoracoscopy and video-assisted thoracoscopic surgery (VATS).
- The acute respiratory distress syndrome in an adult patient presenting with sepsis.
You are the Foundation Year doctor called to see Mr R, a 27 year old man who has presented to the Emergency Department with severe central chest pain. Mr R reports a week's history of fever, myalgia, and loss of appetite; his chest pain developed over the past 24 hours and has increased in severity over the past 2 hours. On examination Mr R was pyrexial (temperature 38.3°C), tachycardic (HR 126 bpm), tachypnoeic (RR 34) with a blood pressure of 64/40mmHg.
- Haemoptysis
You are asked to see a 54-year-old lady who presented to the A&E with a recent history of haemoptysis. She had complained of a worsening cough over the preceding 3 months, though put this down to her smoking, having smoked 5 cigarettes per day since her mid-teens. Over the last 1 week, she had noticed blood on coughing. This was not associated with any shortness of breath or chest pain. She is extremely anxious. She had not been on any recent long haul journeys and has no history of DVT or PE. She had no significant past medical history, and she was on no regular medications. Her family history includes one bother with a history of angina; a father who died of an MI aged 75; and a mother who had TB as a young adult, but is alive and generally well. Initial blood tests show Hb 14.5; MCV 88.6; WCC 7.8; CRP
- Asthma
A 34-year-old lady presents to A&E with a 4-hour history of rapidly increasing shortness of breath and wheeze.
- Smoking cessation
A 52-year-old accountant has recently been diagnosed with chronic obstructive pulmonary disease (COPD). He has smoked 20 cigarettes per day (cpd) since he was 18 years old.
- The unilateral white lung
An 80-year-old woman had been previously diagnosed with non-small cell lung cancer. She attended the emergency department 14 months after the initial diagnosis, with increased shortness of breath, lethargy, reduced appetite and generalised weakness. She had a past medical history of type 2 diabetes mellitus, currently requiring insulin, hypertension and ischaemic heart disease.
- Management of obstructive sleep apnoea
A 46-year-old shopkeeper, originally from Bangladesh, presents to the sleep clinic after referral by the ENT surgeons. His GP had originally referred him to ENT following complaints from his wife about loud snoring, to which he is oblivious. ENT examination was unremarkable. He is a smoker, drinks alcohol each evening and has no previous medical history, however, his blood pressure is under surveillance in the community and he has recently had some blood tests to look at his blood glucose and lipids. His wife is upset that her husband has changed, is becoming withdrawn and she has had to move to sleep in another room in the house. He feels un-refreshed after a night's sleep and his wife also reports finding him asleep on the sofa when she return from work in the evening. His BMI is 30, oxygen saturations of 96% and normal spirometry.
- Bronchiectasis: not all coughs and dyspnoeas are COPD!
We are presenting two different patients with similar pulmonary condition but with different underlying aetiologies. In one patient, the condition was diagnosed and then managed. The other patient was already known to have the condition and presented with one of its complications.
- An unusual infection presenting as a chest wall mass
A 54-year-old smoker was referred by her GP with a history of a painful lump in the left breast of 4 days duration. Past medical history consisted of type 2 diabetes, hypertension, chronic back pain and irritable bowel syndrome.
- Cystic fibrosis
A 1-year-old boy is brought by his mother to see his GP with a persistent cough, wheeze and foul smelling stools. The mother reports a history of recurrent chest infections since birth and the GP notes that the child is below the appropriate centile for weight gain. How would you further assess and manage this patient?
- Management of recurrent infective exacerbations of bronchiectasis
The rate of non cystic fibrosis (CF) bronchiectasis is increased due to increase diagnosis and to aging. This is a chronic respiratory condition associated with abnormal irreversible bronchial airway dilatation. The condition is characterised by recurrent airway infections, persistent symptoms of cough and sputum production and a subsequent decline in respiratory function. It often results in patients requiring multiple hospital admissions. As a foundation junior doctor you may be expected to manage patients with bronchiectasis. This article is a case-based discussion on a patient presenting repeatedly with infective exacerbations of bronchiectasis. It covers recognition of the unwell patient with an infective exacerbation and details the investigations and management that should be instigated. Bronchiectasis may be the result of a previous respiratory infection or an underlying systemic disease however in many cases it is idiopathic. Management of bronchiectasis should be targeted at both the acute presentation of an infective exacerbation as well as improving chronic respiratory symptoms and preserving respiratory function. Treatment should be tailored to the patient and their symptoms and is multimodal including airway clearance techniques, mucolytics and antibiotics. There is evidence that long term oral and nebulised antibiotic use is beneficial in sub groups of patients with bronchiectasis.
- Hypersensitivity pneumonitis
A 63 year old female with a previous radiological diagnosis of hypersensitivity neumonitis (HP) presented to the Accident and Emergency Department for the third time in 8 years. No known allergen had been identified. She complained of progressive shortness of breath, a dry cough and a significant reduction in exercise tolerance. Salient investigations included an arterial blood gas (ABG) which confirmed hypoxia and a high resolution CT (HRCT) scan of the chest revealing bilateral interstitial pulmonary infiltrates. A diagnosis of recurrent HP was made and the allergen identified as goose feather from household bedding products. HP is a relatively uncommon, yet important cause of progressive breathlessness. It is caused by recurrent inhalation and sensitisation to certain allergens resulting in a hypersensitivity reaction. It is treated with oral corticosteroids. If left untreated it can progress to irreversible pulmonary fibrosis. Identifying the allergen to facilitate allergen avoidance is crucial to its management. This case highlights the process of investigating and managing patients with HP, the challenges of identifying the responsible allergen and how this impacts patient prognosis.
- Investigations and management of lung cancer
Lung cancer is the second most common cancer diagnosed in the UK. The investigations and management of patients with lung cancer remains complex. In the UK it involves a multidisciplinary team approach, which includes close working between respiratory physicians, oncologists, cardiothoracic surgeons, radiologists, histopathologists, palliative care team and specialist nurses. The investigations of patients with lung cancer have also become multifarious, as new technologies such as positron emission tomography scanning, endobronchial or endoscopic ultrasound have acquired wider use. Moreover, the management of patients with lung cancer has become more complex as new chemotherapy and radiotherapy modalities have been developed. The understanding therefore of the modes of presentation of patients with lung cancer is pivotal as it may result in early detection. Moreover the awareness of investigational pathways and therapeutic options remains an important aspect of managing this devastating condition.
- Management of the cystic fibrosis patient in the medical assessment unit
Cystic fibrosis (CF) is an autosomal recessive multi-system disease that can result in different presentations in the acute setting. Managing CF can be challenging and daunting for the foundation doctor. A stepwise approach, with input from the local CF team, can ensure that patients are managed as a whole. We will discuss the management of common presentations.
- The impact of obstructive sleep apnoea in pregnancy
Obstructive sleep apnoea (OSA) is a condition of increasing prevalence worldwide. The number of patients affected is likely to continue rising, in keeping with the global epidemic of obesity, one of the conditions strongest risk factors. Over the last decade, there has been an increase in the work done to address the characterisation, investigation and management of patients with OSA as well as to identify the associated co-morbidities which lead to significant morbidity and mortality. There is evidence linking OSA to an increased risk of hypertension, cardiovascular disease, stroke, pulmonary hypertension and type 2 diabetes mellitus, as well as a reduced quality of life, mood disturbance and increased incidence of road traffic accidents. More recently there has been growing evidence that these risks can be extrapolated to pregnant patients with links being demonstrated between maternal OSA and poor perinatal/pregnancy outcomes. This article will discuss with the use of an illustrative case the current evidence about the impact of OSA on pregnant patients.
- Early diagnosis of obstructive sleep apnoea
Obstructive Sleep Apnoea Syndrome (OSAS) describes a disordered sleep breathing pattern associated with recurrent apnoea and a range of symptoms including daytime somnolence. It is becoming increasingly common as the prevalence of obesity rises. Evidence demonstrates a significant impact on quality of life and increased risk of several co morbidities which can be improved with safe non-invasive treatment in the form of continuous positive airway pressure (CPAP). As a foundation doctor you will inevitably see patients with symptoms of OSAS and this article provides you with the tools to highlight those at risk and make the diagnosis early.
- Pulmonary embolism: when D-dimer is not a useful test
D-dimer is a test commonly used to exclude pulmonary embolism (PE) due to its high negative predictive value. This case report describes a patient with new pulmonary embolism who was classified as 'moderate risk' according to the Well's score but had a negative d-dimer test. The diagnosis was confirmed with pulmonary angiography. This case effectively illustrates the rationale behind current guidelines on the diagnosis of pulmonary embolism. Guidelines state that a negative d-dimer test can exclude PE in 'low risk' patients according to the Well's score, whilst d-dimer is not useful in 'high risk' patients as a significant proportion will still have PE. However, in 'moderate risk' patients clinical usefulness of the d-dimer test depends on the sensitivity of the assay used. In this hospital we use only a moderately sensitive assay which is unable to exclude PE in this patient group.
- The many faces of sarcoidosis
Sarcoidosis is a multisystem inflammatory disease of unknown aetiology. Its incidence is difficult to determine due to significant heterogeneity in disease presentation and severity among different ethnic and racial groups and geographical variation. We present a case that illustrates biochemical, radiological, and pathological abnormalities in sarcoidosis. We discuss complications and evidence for treatment in sarcoidosis.
- Breathlessness, lung fibrosis and the limitations of Occam's razor
We present an elderly woman who was admitted to hospital with an apparent exacerbation of a chronic condition. Investigation revealed that her symptoms and signs were caused by three pulmonary pathologies. One was previously diagnosed, one was acute and one became apparent for the first time after admission. We take this opportunity to discuss not only the current guidance available for the management of one of this patient's pathologies, idiopathic pulmonary fibrosis, but also to take a lateral-thinking look at the changing principles of diagnosis and management in an acute medical world populated by many patients of advanced age with pathology in multiple systems.
- A patient presenting with acute onset breathlessness, fever, respiratory failure and abnormal chest X-ray
This case report is about a 38 year old teacher who presented with an acute febrile illness, dyspnoea and respiratory failure. Chest X-ray and CT scan revealed bilateral multifocal consolidations. A diagnosis of organising pneumonia was made after exclusion of community acquired pneumonia (CAP). Organising pneumonia can mimic CAP and early suspicion and diagnosis can lead to treatment with steroids which leads to rapid resolution of symptoms, clinical and radiological signs. Although the reported mean annual incidence is around 1.97/100,000 population, it is thought to be commoner than generally considered. If not treated early, it can progress rapidly and lead to respiratory failure needing ventilatory support. The differential diagnosis and specific investigations of multifocal consolidations followed by management strategies are discussed in the article.
- Rheumatoid arthritis
A 42-year-old woman presents to accident and emergency. She has been feeling feverish for 48 hours, has a dry cough and is short of breath on exertion. She has no history of respiratory disease. Over the last month she has felt increasingly fatigued on exertion. She has had rheumatoid arthritis for 6 years which has been well controlled on methotrexate 15 mg once weekly. She also takes diclofenac 50 mg as required and folic acid 5 mg once weekly. She is a non smoker.
- Mixed connective tissue disease
A 53-year old female with a previous history of non-specific arthralgia, myalgia and Raynaud’s phenomenon was admitted with chest pain, dyspnoea and cough. She was found to have overlapping features of lupus, scleroderma and polymyositis along with raised inflammatory markers and anti-ribonucleoprotein antibodies. She was diagnosed as having Mixed Connective Tissue Disease and was started on immunosuppressive therapy with a good response. This case-based discussion describes the process of diagnosis and management of this patient.
- Clinical problems with biologic therapies
A 32 year old female with rheumatoid arthritis presents with a two day history of abdominal pain, dysuria and fever. She feels lethargic, nauseated and is unable to tolerate anything orally.
- Weakness and wheezing in a young woman
A 32-year old Asian woman presented with a 2-week history of weakness and tingling in her right arm and leg. She also reported a rash over her right leg. She had a past medical history of asthma. Clinical examination revealed an erythematous rash over her lower leg. On chest auscultation she had fine bibasal inspiratory crackles. Blood results showed raised inflammatory markers, a peripheral blood eosinophilia and a negative ANCA. A high resolution CT chest showed ground glass shadowing consistent with interstitial lung disease. A biopsy of the skin rash demonstrated eosinophilic vasculitis. Based on these findings, a diagnosis of Churg-Strauss vasculitis was made. The patient responded well to intravenous corticosteroid and cyclophosphamide therapy with rapid resolution of her vasculitis.
- Dactylitis
Dactylitis or ‘sausage-like digits’ is the inflammation of a finger or toe, affecting any of the structures within a digit. It can occur in patients of all ages and can be overlooked during routine history and examination. It is important to be aware that dactylitis is often part of a systemic disease, and may be the presenting feature. Using an illustrative case, this article discusses the common, important causes of dactylitis.
- Diagnosis and management of a patient with inflammatory myopathy
We present a case of polymyositis associated with extra-muscular involvement of the lungs and oesophagus. This case discussion highlights the importance of diagnosis and treatment. Early diagnosis of the disease is important, as it is associated with high mortality and morbidity. The aetiology of inflammatory myopathy is poorly understood. However successful treatment with corticosteroids and disease modifying agents can greatly improve quality of life and reduce relapses of the disease.
- An approach to managing a hot, swollen joint
A 51-year-old man presents to the A&E department with a hot, swollen, painful knee (Figure 1). He says it started yesterday and is gradually getting worse. He is now finding it difficult to walk. He is usually fit and well, and was able to play football last weekend with his son. He has taken paracetamol with little effect. On examination his right knee is warm to touch. There is a moderate effusion. His knee flexion is restricted to 70 degrees and he is unable to fully extend his knee. The rest of the musculoskeletal examination is normal.
- Inflammatory back pain
This is a case summary based on a 28 year old man with a two year history of lower back pain and stiffness. The article highlights his clinical history, examination, investigations and multidisciplinary management.
- Loa Loa reactive arthritis
We describe a unique case of reactive arthritis secondary to Loa Loa filariasis after treatment with anti-helminthic therapy. The case highlights that in patients with unclassifiable oligoarthritis, who have travelled abroad, reactive arthritis due to parasitic infections should be considered in the scope of differential diagnoses. Furthermore, one must distinguish between musculoskeletal involvement during parasitaemia and reactive inflammatory disease to either the infection itself or, as in our patient, the helminthic carcasses. Reactive arthritis should be monitored for after anti-helminthic treatment for filariasis, so that early appropriate treatment and rehabilitation can be instituted to prevent long-term sequelae.
- Sarcoid arthropathy
A 42 year old Afro-Caribbean male attended the rheumatology clinic with a 4 year history of swelling of the joints in his hands. He denied early morning stiffness, joint involvement elsewhere, dry eyes or mouth, Raynaud’s phenomenon or weight loss. He was diagnosed with sarcoidosis 5 years previously following a biopsy of a 1cm lump in the posterior triangle of his neck, which showed non-caseating granulomas, and a chest radiograph showed bilateral hilar lymphadenopathy.
- Temporal arteritis
Temporal arteritis (or giant cell arteritis) is a chronic vasculitis affecting large and medium vessels. We present a case based discussion encompassing the presentation, investigations, management and complications of temporal arteritis.
- Psoriatic arthropathy
Inflammatory musculoskeletal symptoms in the setting of psoriasis are suggestive of psoriatic arthritis. This affects 6-30% of individuals with psoriasis. Joint manifestation typically follow skin disease but may precede it. Joint involvement can vary considerably from an isolated monoarthritis to an extensive destructive polyarthritis. The commonest presentation is either a monoarthritis or an asymmetrical arthritis only affecting a few joints. Other common features include dactylitis or ‘Sausage digits’, enthesitis: inflammation at the sites where tendons insert to bone, especially Achilles tendonitis and plantar fasciitis. Many patients may be well controlled on NSAIDs alone. Intra-articular steroid injections are commonly used to target one or two inflamed joints. Leflunomide and sulfasalazine are the main stay disease modifying drugs used for persistent disease and Anti TNF drugs are reserved for those with refractory disease.
- The locked knee
A 25-year-old man attends his local A&E department. He presents with a painful swollen knee which is unable to bear weight. He gives a history of having sustained an injury while playing rugby for his club. The injury occurred when he was tackled. His foot became stuck in the soft ground and his upper body twisted as he fell to the ground. He describes a popping noise coming from his knee as he fell. He was carried from the pitch and was driven by a friend to his flat. Over the next 2 hours his knee became very swollen and stiff. The pain became worse. At this stage his flatmates drove him to his local hospital.
- Insufficiency fracture
A 65-year-old lady develops severe lower back and right flank pain. She is admitted to a surgical ward for suspected renal colic.
- Discitis: the cause of a PUO
A 69-year-old gentleman was admitted with a presumed lower respiratory tract infection (LRTI) for which he received treatment on a general medical ward. After a failure to respond to first line antibiotic therapy, the clinical assumption was inferred that this was due to infection with an atypical organism. On deeper clinical questioning the patient revealed mild back pain of short duration that commenced following a recent camping trip. After an unsuccessful response to numerous antimicrobials, investigations were initiated for a pyrexia of unknown origin (PUO). After multiple negative investigations, including plain films of the lumbar spine, a radioisotope (indium) WCC scan was performed.
- Back pain
A 46-year-old woman attended the A&E Department with a 7-day history of severe back pain. Radiation of pain down her left leg started 3 days before attending the hospital. The pain started when she bent down to lift up a heavy flower pot in her garden. She took paracetamol and Ibuprofen without much help with her symptoms. The pain gradually worsened, and she finds it difficult to move from her bed to the toilet and back. There is no history suggestive of bowel and bladder disturbance.
- Systemic lupus erythematosus
A 28-year-old Afro-Caribbean female teacher presents to clinic with an ongoing history of joint pains going back 2 to 3 years. She has recently become more tired and has noted that she becomes short of breath when walking 100 metres, sometimes with sharp stabbing chest pain which comes and goes. Last summer, when on holiday, she developed a facial rash for the first time, which has now disappeared. She has noted that her hands become more stiff and painful in the winter months or when working with cold or frozen material.
- Osteomyelitis
A 42-year-old man was presented to the A&E department with a temperature of 39°C, feeling unwell. Heart rate was 110bpm, blood pressure 100/60mmHg, respiratory rate 24 breaths/minute, oxygen saturation on room air 90%. He had no chest pain, or abnormal neurological findings. Chest auscultation and ECG were normal. He smoked 20 cigarettes/day, and his past medical history was unremarkable. He sustained an open fracture of his left tibia and fibula 8 months previously. This was managed with an ankle spanning external fixation, and open reduction internal fixation of the fibula. The external fixator was removed 4 weeks before presentation at the A&E, and the patient was mobilising with a removable ankle brace. He had pain in his distal tibia and a pus discharging sinus (Figure 1) had developed in the last few days. Radiographs of his left tibia were requested (Figure 2). What is your assessment? How should this patient be managed?
- Scleroderma
A 42-year-old woman was admitted to the Medical Admissions Unit with dysphagia that had worsened over the last few months. Ingesting liquids was particularly problematic. She lost a stone in weight over several months. She denied any other gastrointestinal symptoms. She lives with her husband and recently started to be out of breath while doing household chores. When questioned, she reports that her fingers turned pale on exposure to the cold and that her skin had become thickened over the last few months. Various soothing creams and lotions did not help. She started to experience difficulty opening her mouth lately. On examination, there was sclerodactyly, telengiestasia, calcinosis cutis, microstomia and scleroderma limited to face and hands. A case of Limited Cutaneous Systemic Sclerosis is suspected as the likely diagnosis.
- Vertebroplasty for osteoporotic vertebral fractures
A 70-year-old lady with Parkinson's disease had a mechanical fall and developed acute low back pain. The pain was sufficiently severe to stop her from moving and she was on the floor for several hours before being found by a carer who brought her to the local A&E department. Six years previously she had sustained a crush fracture of the T12 vertebra which had resulted in a prolonged inpatient episode due to pain and reduced mobility.
- Open fracture of tibia and fibula
A 61-year-old male, was brought to the A&E department at around 1am with injury to his right leg. He was under the influence of alcohol and a slow moving motor vehicle hit his left leg, while he was crossing the road. He fell to the ground and could not get up as his left leg was deformed and painful. When the ambulance arrived he was conscious and coherent and he complained of pain in his left leg, which was deformed. A puncture wound was also noted.
- Dupuytren's contracture
A 56-year-old man presents complaining that he cannot get his right ring finger straight.
- An unusual rash in a young woman - differential diagnosis and management of a vasculitic rash with systemic features
We present the case of a young lady aged 28 who developed an extensive skin rash over her lower limbs following a viral infection. The features were those of a palpable purpura and were associated with abdominal pain, diarrhoea which became bloody, arthralgia and asymptomatic haematuria. She had a low grade fever and elevated acute inflammatory markers. A clinical diagnosis of Henoch-Schönlein purpura was made and prednisone commenced at the dose of 20mg daily. A rapid symptomatic improvement followed, with resolution of the abdominal pain and diarrhoea, followed by a more gradual reduction in the rash over several weeks.
- Management of osteoporosis
Osteoporosis is a common disorder with high morbidity and mortality. It is clinically silent until the first fracture. Treatment is often started late and then inadequately reviewed. Foundation doctors will find this article helpful when managing elderly patients presenting with fractures and falls and when making decisions about primary prevention in General Practice.
- A case of polyarticular gout complicated by renal failure
Crystal arthropathy (Gout) is an inflammatory arthropathy caused by uric acid deposition in joints. It can cause significant pain and disability. Although relatively common, treatment can be difficult due to co-morbidities and potential side-effects of medications. We present a case of polyarticular gout complicated by acute renal failure secondary to medication. The case is discussed along with investigations and management.
- Fresh perspective on acute gout for foundation year doctors
Once considered a "disease of kings" due to its association with an affluent lifestyle, gout is now one of the more common forms of inflammatory arthritis. Gout is the clinical manifestation of hyperuricaemia and crystal deposition in joints and soft tissue. This includes arthritis, tophaceous collections, uric acid nephrolithiasis and nephropathy. Most often, gout is understood to refer to the inflammatory arthropathy caused by uric acid crystal deposition (1). The disease is the commonest arthritis of middle-aged men, and prevalence increases with advancing age for both sexes (2). Gout results from the interaction between genetic susceptibility, constitutional components, and environmental triggers. In the UK, 7% of men aged over 75 are affected by gout. The overall prevalence of gout has been increasing, with one study reporting an increase of over 60% from 1997 to 2012 (3). This rise is possibly due to the shift in the population's diet and lifestyle, as well as increased longevity and improved medical care (3). Despite the significant rise in the number of people affected by gout, only around a quarter of people with prevalent gout were prescribed urate-lowering treatment (4). Left untreated, gout can develop into a painful and disabling chronic disorder. Persistent gout can destroy cartilage and bone, causing irreversible joint deformities and loss of motion (5). A more recent study also demonstrated suboptimal care in many aspects of gout management (6). Collectively, these results reflect widespread lack of knowledge of gout and poor alignment with current recommendations of best practice within the UK. In this review we aim to highlight to foundation year doctors the current evidence for the diagnosis and management of acute gout.
- Adult-onset Still's disease
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown aetiology, characterised by daily spiking fevers, arthritis, an evanescent macular or maculopapular rash and an acute-phase response secondary to the production of pro-inflammatory cytokines. Here we described the case of a young adult presenting acutely with this syndrome, complicated by myopericarditis.
- Septic arthritis: a medical emergency about which all foundation doctors must know
Septic arthritis is a medical emergency that all foundation doctors must know about. It typically presents as a single hot, swollen and painful joint. It is caused by infection inside the joint and can progress rapidly to destroy the joint. Even with treatment the mortality from septic arthritis is high. It is therefore vital that foundation doctors are able to recognise and manage this condition. We present a case of septic arthritis and discuss the common difficulties that doctors face.
- Polyarticular joint flare in an immunosuppressed patient with rheumatoid arthritis
We describe the case of a 53 year old caucasian woman with longstanding rheumatoid arthritis, on immunosuppressive therapies presenting with polyarthritis and sepsis. Differential diagnoses including a rheumatoid flare secondary to sepsis and polyarticular septic arthritis needed to be considered. The diagnosis was initially clouded by respiratory symptoms and signs indicating a concurrent chest infection. The case was complicated by transfer out-of-hours between hospitals whilst the patient was acutely unwell. We learn that a Staphylococcus aureus joint infection is the most common in those with underlying rheumatoid arthritis and that the treatment is based on the supportive measures dictated by the 'sepsis six', especially intravenous flucloxacillin immediately after joint aspiration. Additionally, attention needs to be paid to increasing steroid doses and the cessation of methotrexate and biological therapy whilst unwell with an infection. This case highlighted the importance of keeping a differential list in mind, challenging the diagnosis if something does not fit and the importance of communication between multidisciplinary teams, as well as other hospitals, when transferring a patient. The most crucial learning point is the importance of early joint aspiration prior to intravenous antibiotics, to help prevent joint destruction and the morbidity and mortality associated with sepsis.
- Back pain having spinal cord compression
A 54 year old man presented with worsening lower lumbar pain radiating down his thighs and a band-like pain across the upper abdomen. He was known to have monoclonal gammopathy of uncertain significance (MGUS). Initial neurological examination revealed an absent left ankle jerk reflex and reduced sensation over the lateral left calf with a normal digital rectal examination; however on repeated assessment, a right sided foot drop and absence of the right ankle jerk reflex had developed, together with loss of peri-anal sensation. Spinal cord compression was suspected and urgent magnetic resonance imaging (MRI) revealed a diffuse infiltrative process affecting the vertebral bodies, with lesions compressing the spinal cord from T5 to T7 and L4 to S1. Subsequent examination of the bone marrow confirmed the diagnosis of myeloma. It is important to exclude metastases in a patient presenting with back pain when there is a history of malignancy or pre-malignant condition. Furthermore, repeated neurological examination can be essential to detect signs of spinal cord compression.
- A case of granulomatosis with polyangiitis
A 57 year old lady presented with a 3 month history of breathlessness, non-resolving consolidation on chest X-ray, lacrimal gland enlargement, ptosis and orbital pain. Blood investigations showed leucocytosis, thrombocytosis, a normocytic anaemia, elevated C-reactive protein (CRP), normal renal function and urinalysis, and negative anti-neutrophil cytoplasmic antibody (ANCA). A malignancy was suspected, but only after extensive investigations were other diagnoses re-considered. Subsequent biopsy from the lacrimal gland demonstrated granulomatous inflammation with vasculitis and necrosis, consistent with a diagnosis of granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis. It is important to consider vasculitis as a possible diagnosis in patients with multisystem presentations even when ANCA is negative, as in this case, as delays in diagnosis and treatment may have organ or life- threatening consequences.
- Polymyalgia rheumatica (PMR)
Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition and will be frequently encountered during the Foundation course both as a comorbidity in inpatients and as a new presentation to General Practice. It is one of the most common indications for long-term steroid therapy. It is often initially diagnosed in primary care but a significant proportion are referred to secondary care for assistance with diagnosis and management. There is a broad differential diagnosis for patients presenting with proximal pain and stiffness, and many other conditions may mimic PMR. There is an important overlap with giant cell arteritis (GCA). This review discusses aspects of PMR relevant to the Foundation doctor, including the approach to diagnosis and treatment, and highlights which patients should be referred for specialist opinion.
- Neuropsychiatric complications of systemic lupus erythematosus
A 26 year old woman presented with a Brown-Séquard syndrome. She was found to have transverse myelitis and features of systemic lupus erythematosus. Despite treatment she continued to have multiple relapses before developing optic neuritis. Her anti-aquaporin 4 antibodies were positive and she was therefore diagnosed with neuromyelitis optica in addition to systemic lupus erythematosus.
- Management of the hot swollen joint H in adults in the Emergency Department
Though septic arthritis needs to be excluded when a patient is seen as an emergency, other causes of the hot red swollen joint such as gout, pyrophosphate and psoriatic arthritis, palindromic rheumatism and acute sarcoidosis, can be diagnosed with careful history, physical examination and simple investigations. The joint aspirate needs to be Gram stained, cultured and sent for polarised microscopy. Intra-articular corticosteroids should not be injected unless septic arthritis is confidently excluded. Swollen prosthetic joints are best referred urgently to the orthopaedic team.
- The management of major trauma
Major trauma is the leading cause of death in those aged under 40. There are three times as many left permanently handicapped. For each individual trainee their exposure to major trauma is limited. The patients condition rapidly changes, large amounts of information need to be processed, involvement in a multidisciplinary team both medical and none medical contribute to the fears of the young doctor presented with the unknown. There may be more than one patient; those involved may have non-survivable injuries. The reality of a major trauma case is very different from that portrayed in Holby City or ER.
- Wound management and suturing
An 82-year-old woman presents to the Emergency Department (ED). She fell against a door and has sustained a laceration to the dorsum of her left hand.
- Renal trauma
Renal trauma occurs in approximately 1–5 % of all trauma. The kidney is the most commonly injured genitourinary organ, with a male to female ratio of 3:1. The majority of renal injuries can be managed conservatively, although occasionally it can be acutely life-threatening. Approximately 10% of patients sustaining abdominal trauma have an injury to the genitourinary tract (1-4).
- Principles of wound care in the Emergency Department
A seventy-nine year old female patient fell onto a garden cane which penetrated the right side of her face. The management, radiological investigation, anatomy of the injury and complications are presented as the basis for a Case Based Discussion.
- Management of chest trauma in the Emergency Department
A 48 year old man was brought to the Emergency Department by airambulance after colliding into a cliff face whilst paragliding; he had then fallen a further 5 feet to the ground. The pre-alert call to the Emergency Department suggested he had sustained significant thoracic injuries.
- Pelvic fracture management
Following a high speed road traffic accident a patient is airlifted to hospital where the trauma team are assembled. The case is used to illustrate the management of high energy pelvic injuries, and the management of major haemorrhage in this context. Low energy pelvic injures are not considered.
- Infected needlestick injuries
Needlestick injuries (NSI) are a relatively common occurrence within the healthcare setting. In this article, we outline the risks involved and how to go about managing a needlestick injury.
- Management of head injury
The assessment and management of head injury patients can be a daunting task for Foundation year doctors. This article emphasises the importance of accurate history taking and examination when assessing these patients and will discuss management of a difficult, yet common scenario.
- Acute complications of transurethral resection of prostate (TURP)
Mr X is a 60-year-old gentleman who presented with a history of frequency, nocturia, hesitancy and dribbling. He is very annoyed by the fact that he wakes up every two hours at night to void very small amounts and that he needs to be close to a toilet all day long! He also has recurrent UTIs
- Acute pyelonephritis
A sexually active 28-year-old woman presents to the surgical admissions unit with a 2 day history of left loin pain, fever, nausea and vomiting. Preceding this she describes urinary frequency, urgency and dysuria. She is otherwise fit and well. On clinical examination she looks flshed and sweaty and her temperature is 38.5°C. She is tachycardic (105bpm) but normotensive (110/75 mmHg). She is tender in the left renal angle. Otherwise her abdomen is soft with no palpable organomegaly or masses. Dipstick urinalysis shows blood, protein and nitrites. Urine pregnancy test (βHCG) is negative.
- Urinary catheter insertion
You are on call as the night junior doctor and you are asked to catheterise a patient on one of the surgical wards. The patient is a 67-year-old gentleman who is day 1 post op having had an inguinal hernia repair under general anaesthetic. He has been unable to pass urine for 8 hours and is in severe distress. On examination he has a palpable mass in his abdomen arising from the pelvis which is smooth, uncomfortable to palpate and has a dull percussion note.
- Acute urinary retention
A 65-year-old man presents to the emergency department with a sudden inability to pass urine associated with suprapubic pain and discomfort. He also gives a 6 month history of poor stream, hesitancy and frequency. He was previously fit and well and on no regular medication. On examination, patient is in obvious discomfort with a pulse rate of 100 and a blood pressure of 130/80. Examination also reveals tender suprapubic area with a possible mass. The patient’s bedside ultrasound shows residual urine of more than 500 ml in the urinary bladder.
- Urological emergencies
A 58-year-old patient (smoker) is admitted to the Emergency Department by his GP with severe right-sided loin pain radiating into the right lower abdomen.
- Gout: treatment and renal complications
A 68-year-old gentlemen presented to A&E with a 1-week history of being “off his legsâ€. On examination he was drowsy and febrile. He was admitted and treated for a urinary tract infection as he had a neutrophilia and the presence of blood and protein in his urine. In the past, he had been treated for hypertension, a stroke and non-specific c arthritis. Over the 5 days subsequent to admission, he developed oedema, severe hypoalbuminaemia and proteinuria and his C-reactive protein (CRP) rose to over 500. Blood cultures came back negative for organisms. It was noted that asymmetrical synovitis and bilateral knee and shoulder effusions had developed. Joint aspiration revealed negatively birefringent crystals and no organisms were seen or cultured. Tophi were noted on his pinnae and distal interphalangeal joints. A diagnosis of acute polyarticular gout with associated nephrotic syndrome was made. He received colchicine orally and underwent arthroscopy and lavage of his knees and shoulders. His symptoms and nephrotic syndrome resolved and he was discharged on regular allopurinol. He recovered well after a period of rehabilitation in a community hospital.
- Management of renal colic
A 66-year-old male presents to accident and emergency with a 4 hour history of left sided loin to groin pain. He has minimal dysuria or urgency. There is no frank haematuria. He is haemodynamically stable. Past medical history includes hypertension, treated with bendroflmethiazide and atenolol. He is a smoker of 20 cigarettes per day since his teens. Examination reveals mild tenderness on the left loin. The patient is writhing around the bed, unable to get comfortable.
- Urine dipsticks
The urine dipstick is a common investigative tool used in all branches of medicine. It detects a number of different substances in the urine through a series of chemical reactions. This case-based discussion aims to provide a framework of what to do when faced with various urine dipstick results.
- Testicular torsion
This case-based discussion focuses on the case of a 17 year old student presenting in the early hours of the morning to the emergency department with acute left hemi-scrotal pain and discusses the evaluation and management of his condition.
- Prostate cancer screening and diagnosis.
This discussion is based on the diagnostic pathway of a 55 years old man with a family history of prostate cancer. As well as explaining the assessment and process of investigation it also addresses the controversies of screening patients for prostate cancer.
- Urinary retention and renal failure
A 72 years old male is referred by the GP to the surgical assessment unit with dribbling of urine, nocturnal incontinence, suprapubic swelling and renal failure.
- Renal colic
This case-based discussion focuses on a 54 year old male presenting with a history suggestive of renal colic. We will discuss general assessment, examination, investigation and management.
- Andrology
A 61 years old diabetic patient presents to his General Practitioner complaining that his erections are progressively getting weaker. The problem has been present for several months but is now causing marital difficulties.
- Benign scrotal swellings
Scrotal swellings are frequently seen in children and adolescents and are not uncommon in the adult population. The list of differential diagnoses is vast but, as in all patients, can be narrowed down by a thorough history and physical examination (1). Since the potential causes range from mundane to life-threatening, patients may present to their general practitioner or acutely to the emergency department. Therefore, its relevance is widespread.
- Acute penoscrotal emergencies
In this article, we aim to highlight those penoscrotal emergencies that may present throughout a urological on call shift. These emergencies, whilst not common are of great interest and can be managed entirely or in part by a Foundation Year doctor.
- Interstitial cystitis and ketamine-induced vesicopathy
Interstitial Cystitis (IC) is a chronic distressing bladder condition, which is difficult to diagnose and hence manage. We describe the case of a 30 years old lady presenting with symptoms of suprapubic pain associated with bladder filling and discuss the management and treatment options.
- Simple urinary tract infection (UTI)
This case-based discussion focuses on a patient presenting with a simple Urinary Tract Infection (UTI). It covers the assessment, differential diagnoses and management of the condition.
- Catheterisation
Urethral catheterisation is often perceived as a simple procedure that requires little training. However, although catheterisation is usually performed without complication, there are instances, where it causes significant problems such as sepsis or urethral trauma. As catheterisation is commonly performed these instances are more prevalent than most non-urologists appreciate. This case covers the indications for catheterisation, types of catheters and the pit-falls and complications that can arise and how to deal with these. Basic catheterisation technique will also be covered in order to help junior doctors perform the procedure safely and effectively and recognise when things have gone wrong! Finally three specialised situations are discussed that may be encountered by on-call junior doctors; suprapubic catheters, 3-way catheters and irrigation, and self catheterisation.
- Prostatitis and chronic pelvic pain syndrome
This discussion is based on a 39 year old gentleman presenting with prostatitis and discusses the assessment, differential diagnosis and treatment of the condition.
- Epididymitis
This case-based discussion focuses on a 32 years old gentleman presenting with epididymo-orchitis and discusses the assessment, differential diagnosis and treatment of the condition.
- Bilateral emphysematous pyelonephritis
A 35-year-old non-diabetic female with a history of urolithiasis presented with loin pain. CT scan revealed bilateral EPN. Initial cultures of aspirate from a perinephric collection grew streptococcus milleri and multiple anaerobes. Treatment entailed high-dose antibiotics and percutaneous drainage. The patient made a good recovery and was discharged home after 38 days of hospitalisation.
- Long-term urethral catheterisation
A 68-year-old patient recently had spinal trauma and is undergoing rehabilitation. He is experiencing recurrent urinary tract infections. His bowel functions are also impaired and require regular laxatives. He has paraplegia below the level of T10.
- Bladder outflow obstruction
Mr X, a 54-year-old gentleman is referred by his GP to the urology FY2 on call with a 24-hour history of being unable to pass urine and increasing suprapubic abdominal pain. A working diagnosis of acute urinary retention is made.
- Benign prostatic hypertrophy / hyperplasia
Mr Smith, a 75-year-old retired postman was referred to A&E by his GP unable to pass urine. Mr Smith contacted his GP urgently after he had been unable to pass any amount of urine and feeling as though his "bladder was bursting". This is the first time this has happened. Mr Smith describes a 7-year history of nocturia of >5 episodes per night, poor urinary flow and incomplete emptying of his bladder which have worsened significantly over the past few weeks. On further questioning you find that he is currently being managed as an out-patient by a Consultant Urologist at your hospital for his lower urinary tract symptoms (LUTS). He has no other co-morbidities, no allergies and has been taking an alpha-blocker for the past 5 years which although initially gave some symptom relief, now "makes no difference at all".
- Bladder training urinary incontinence
A 42-year-old lady with a history of diet controlled diabetes mellitus and well-controlled hypertension was referred to the urology outpatients. She has hourly daytime micturition frequency, associated with urgency and occasional involuntary urine leakage. She previously had two normal vaginal deliveries. These symptoms are affecting her life significantly and stopping her from indulging in social activities and gatherings. The patient is keen to have active intervention (operation) and wants to get better soon.
- Urodynamics
Mr RA is a 54-year-old gentleman referred by his GP for lower urinary tract symptoms (LUTS) with poor urinary flow, nocturia, increased daytime urinary frequency and urgency with occasional urge incontinence. He also complains of right loin pain but denies haematuria or dysuria. He has type 1 diabetes and his current medications include insulin, tamsulosin (400μg ODS) and tolterodine (2mg ODS). He is a non-smoker.
- Stress urinary incontinence: role of pelvic floor exercises
A 38-years-old lady has been experiencing episodes of urinary leakage for the last three years. Her symptoms were just occasional occurring once every 2–3 days but her condition deteriorated after she delivered her last baby a year ago and symptoms became more frequent on a daily basis especially when she coughs, sneezes or laughs, for which she had to seek medical advice.
- Consent of a TURP patient
A 72-years-old patient presented to urology pre-assessment clinic (PAC) for a transurethral resection of the prostate (TURP). His initial presentation was with acute urinary retention. His subsequent trial without catheter (TWOC) in the community was unsuccessful.
- A single episode of visible painless haematuria
A 75-year-old male presented with a single episode of visible painless haematuria and a history of frequency and urgency for 4 months. Two years ago he had a routine medical check-up and was found to have 2 microscopic haematuria. There was no history of UTI. He used to work at a dye factory and smoked 20 cigarettes a day. Examination was unremarkable.
- Post-obstructive diuresis
This paper discusses the diagnosis and management of post-obstructive diuresis (POD). Knowledge of this condition will improve the clinical management of patients with bladder outflow obstruction in the acute setting. We present the clinical case of a 61-year-old man who presented with bladder neck obstruction secondary to metastatic prostate cancer, who subsequently developed POD. We discuss the diagnosis and management of POD from both a pathophysiological and clinical perspective with an emphasis on important definitions and clinical guidance for foundation trainees. This paper covers a relatively uncommon condition but in understanding its management, the foundation trainee will manage patients with bladder outflow and ureteric obstruction with greater understanding and accuracy.
- Pelviureteric junction obstruction
Pelviureteric junction obstruction (PUJO) is more frequent in children than adults. Congenital or acquired narrowing of the proximal ureter causes urinary outflow obstruction resulting in hydronephrosis and potential renal impairment. PUJO may be asymptomatic and found incidentally on imaging or present acutely with loin pain, pyrexia or both. Radiological, nuclear imaging and occasionally endoscopic procedures are required to demonstrate the cause and its functional effects.
- A practical procedure for suprapubic catheterisation
Suprapubic catheters are inserted into the bladder through the abdominal wall. They are usually indicated in cases of failed urethral catheterisation or for long-term catheterisation in certain patient groups. There are a number of techniques of insertion, including the use of a trocar or the Seldinger technique. The most serious complications relating to insertion is the potential for bowel perforation. Commonly, troubles with changing the catheters can present acutely to urology units. The British Association of Urological Surgeons' (BAUS) guidelines for the insertion, management of complications and the long term follow up of suprapubic catheters, is a useful reference for what can be a daunting clinical situation.
- Suprapubic catheterisation
An 80-year-old male presents to the A&E department complaining of lower abdominal pain and an inability to pass urine. The history of this complaint starts a few days previously when his existing, but largely tolerated LUTS became steadily worse.
- Tuberous sclerosis associated renal cell carcinoma
We present an interesting case of a 20 year old male with Tuberous Sclerosis, a rare autosomal dominant condition characterised by multi-organ hamartomas. This condition is expressed with huge variability across patients, with multiple extra-hamartomatous manifestations including; seizures, learning difficulties, behavioural problems, skin conditions and other multi-organ complications. In addition to the well-documented hamartomas, these patients can present with malignant tumours and here we discuss the unfortunate case of a 20 year old male with an incidental finding of a 65mm renal cell carcinoma picked up on routine Computed Tomography (CT) imaging.
- Stress urinary incontinence in women
This case based discussion presents the case of stress urinary incontinence (SUI) in a woman and describes the presentation, clinical history, investigations and treatment for this condition. Good clinical care and patient management parts of the Foundation programme curriculum are covered in this article. The article also discusses different types of continence surgery and potential complications as well as the current controversies surrounding the use of vaginal mesh in urogynaecological surgery.
- Urinary tract infections (UTIs): evidence based treatment
Urinary Tract Infections (UTIs) are common and are encountered in almost all fields of medicine. Evidence based treatment of infections is essential to limit the emergence of resistant strains of bacteria. Foundation doctors will be involved with treatment of UTI's in their first years of practice. Prompt investigation, treatment and referral for Urological intervention in accordance with up to date evidence should help to reduce the morbidity of UTIs and help prevent bacterial resistance.
- Urinary retention in males
There are several causes of urinary retention. This article focuses on urinary retention in the elderly male patient with benign prostatic hyperplasia (BPH), which represents an important public health and quality of life issue. The incidence of this increases significantly with advancing age, and can have health consequences such as renal impairment and urinary tract infection. Foundation year doctors will come across many patients with urinary retention both in hospital and the community. This article should provide some background into the aetiology, and an initial approach to the management of the patient in urinary retention.
- Initial assessment of patients presenting with visible haematuria
Visible haematuria (VH) is a common presentation in both the primary and secondary care setting. Knowledge of assessing and managing such patients is an essential skill for a foundation doctor, doctors working in Accident and Emergencies (A&Es) and primary care physicians. A case based discussion is presented taking a patient through history, examination, investigations and initial management as well as elaborating on typical haematuria clinic work up later.
- Genitourinary tuberculosis: a rare problem in the UK but one that needs to be suspected in high risk groups
In developed countries, the knowledge of diagnosing and managing tuberculosis (TB) and how it can affect the genitourinary system, for most junior doctors, is gained solely from textbooks. Although this should be hailed as a success story, the surge in intercontinental travel over the past decades highlights the importance of having knowledge of a disease with a global incidence of 8-10 million per year. Genitourinary tuberculosis (GUTB) is very rare in the UK and very few junior doctors would routinely think about it when managing urological problems. If left untreated, GUTB poses a great risk for public health as well as the patient. Catching it early and ensuring therapy adherence reduces the need for radical surgery and prevents the rise of multidrug-resistant strains. This review article aims to educate junior doctors on the pathophysiology, clinical manifestation, diagnosis and management of GUTB.
- Diagnosis and management of urosepsis
Urosepsis is defined as sepsis syndrome caused by a urogenital tract infection. Overall, it accounts for approximately 25% of all sepsis cases. It is seen in both community-acquired and healthcare associated infections and it is associated with significant mortality rate. Generally, it is seen more frequently in patients with structural or functional abnormalities of the urinary tract. Understanding the complex pathophysiology of urosepsis is of paramount importance. Accumulating evidence suggests that cytokines play a central role in the pathogenesis of urosepsis by initiating a cascade of immune responses eventually leading to tissue-damaging inflammation. Early diagnosis and prompt management with adequate life-support measures, appropriate antibiotic treatment and reversal of any complicating factors are critical steps in the successful management of urosepsis. It is essential that urologists work in close collaboration with intensive care, radiology and microbiology specialists to provide the best conditions for improving patients' survival.
- Assessment of female patients with missed iatrogenic Injuries to the ureter and bladder following pelvic surgery
This article focuses on the recognition of symptoms, appropriate assessment and management of the female patient with delayed presentation of iatrogenic uro-genital fistula. The term fistula describes an abnormal connection between two epithelised structures i.e. colovesical fistula (fistula between bowel and urinary bladder), anorectal fistula (fistula between rectum and perianal area), vesico-vaginal fistula (VVF). Uro-genital fistula is an abnormal (pathological) tract between urinary and genital organs.
- Acute scrotal pain and swelling in paediatric and adolescent patients: diagnosis and management
Doctors working in the Emergency Department will encounter cases of children and adolescents presenting with acute scrotal pain and swelling. This discussion focuses on the three most common primary causes. An informed clinical diagnosis relies on the history, physical examination, and appropriate investigations. The most serious cause of acute scrotal pain and swelling is spermatic cord torsion (SCT). Urgent scrotal exploration, within 6 hours of the onset of pain, is required to salvage the testis before irreversible testicular necrosis occurs. The other two common causes of acute scrotal pain and swelling are testicular appendage (hydatid of Morgagni) torsion and epididymo-orchitis. These can be safely managed with conservative and medical treatment respectively. Doctors should be mindful that there is a wide differential diagnosis for scrotal pain and swelling which falls beyond the remit of this discussion. In this discussion, spermatic cord torsion implies intravaginal spermatic cord torsion, and omits discussion of extravaginal spermatic cord torsion which classically affects the perinatal population.
- The Use of heparins for the treatment of pulmonary embolism
Mrs VT has been brought in to A&E by ambulance following collapse after sudden onset of shortness of breath and chest pain. She has a past medical history of COPD. She is found to be tachycardic, hypotensive and peripherally shut down. Her left leg is signifiantly swollen. A 12 lead ECG reveals a sinus tachycardia with t-wave inversion in the precordial leads. CXR demonstrates changes consistent with COPD only. You suspect a massive pulmonary embolism (PE) and request an urgent computed tomography pulmonary angiogram (CTPA).
- Deep vein thrombosis
A 74-year-old man, with a past history of an above knee deep vein thrombosis (DVT), presented to his local hospital casualty department with a 2-day history of a swollen, red tender left calf. His left calf was markedly more swollen when compared to his right calf and was especially painful when walking. These symptoms appear to have initially started after disembarking from a long haul flght from Japan.
- Ruptured abdominal aneurysm
A 65-year-old retired builder was admitted to casualty following a collapse. He was tachycardic and hypotensive with an increasingly distended abdomen. He was becoming drowsier and complaining of generalised abdominal and back pain. Previously he had suffered a myocardial infarction and was diabetic. He smoked 20 cigarettes a day and was clinically obese. On examination, he was cold, clammy and distressed. His abdomen was generally tender, distended, tense and pulsatile.
- Pharmacological management of carotid artery disease
A 66-year-old gentleman, with a past medical history of hypertension and hypercholesterolaemia (both of which were diet controlled), presented with a tingling sensation in his arms and blurred vision temporarily. A duplex scan showed 60% stenosis of his right carotid artery.
- Diagnosis and management of iliofemoral deep vein thrombosis
Lower limb deep vein thrombosis (DVT) commonly results in hospital admission. The management of ilio-femoral DVT (IF-DVT) increasingly involves the intervention of vascular surgeons and interventional radiologists to obviate the risks of long term complications. We present the subject to the Foundation Doctor and emphasise essential points in the care of these patients.
- Venous leg ulcer
There are approximately half a million people in the UK with chronic relapsing leg ulcers, with approximately 25% of them being open and ulcerated at any one time. The other 75% are temporarily healed and will recur. The mainstay of treatment has been elevation, outpatient dressings, compression bandaging or support stockings. Increased understanding of venous physiology has meant that the majority of venous leg ulcers can now be cured surgically with improved quality-of-life for patients and reduced costs for ongoing patient care.
- Varicose veins and pelvic venous incompetence
Varicose veins have long been thought to only occur from venous reflux in either the great saphenous vein or the small saphenous veins. Over the last few years, it has become increasingly understood that pelvic venous incompetence is a major contributing factor to leg varicose veins in 20% of women who have had children by normal vaginal delivery. Research, shortly to be published, has shown that the failure to treat the pelvic venous reflux in these patients appears to be a major cause of recurrent varicose veins.
- Management of arterial thoracic outlet syndrome
This article discusses a case of thoracic outlet syndrome (TOS) complicated by arterial compression in a 40 year old man. This condition requires a high index of suspicion to diagnose, with many patients misdiagnosed for several years. This article further considers the clinical features, investigations and management of TOS. With appropriate multi-disciplinary team (MDT) input and tailored therapy, symptoms can be managed successfully with good outcomes.
- Management of acute & acute on chronic leg ischaemia
A 55 year old male type 2 diabetic (NIDDM) was referred to the surgical admissions unit unwell with signs of sepsis and a painful right foot. There was no history of trauma but symptoms of claudication were evident on direct questioning. Over the last 2 weeks he had struggled to mobilise on his painful foot and had been housebound as a result, being cared for by his wife. Overnight he developed increasing pain and partial numbness in his foot at rest.
- Renal artery stenosis
Hypertension and renal impairment are common problems encountered in patients on hospital wards. Whilst most cases of hypertension are primary (or essential hypertension), some cases are secondary. Renal artery stenosis (RAS) is an important cause of secondary hypertension that is increasing in prevalence particularly in the western world, however it remains under diagnosed (1). It is a narrowing of the artery that supplies one or both kidneys. Patients typically present with hypertension and varying degrees of renal impairment, however silent renal artery stenosis may be present in patients with vascular disease. Here, we discuss the aetiology of renal artery stenosis, the clinical features that should make you suspect the diagnosis and importantly which patients would benefit from revascularization and how this is achieved.
- Abdominal aortic aneurysm facts & screening programme
A 65 year old retired clerk, with background of hypertension and ex-smoker is referred to you by the GP with an abdominal aortic aneurysm (AAA). It was an incidental finding on a recent abdominal CT scan for possible diverticular disease. It measures 3.5cm in diameter. On examination there are good peripheral pulses and the abdomen is soft, non-tender with small pulsatile mass palpated. The patient is very anxious about his diagnosis and worried about complications.
- Consent in amputation secondary to vascular disease
A sixty year old male life long smoker with a past medical history of diabetes, hypertension and chronic renal failure presents urgently to your out patient clinic with severe pain in his right foot. It is worse at night and was previously relieved by standing, but now remains constant. He has been managing the pain with a combination of NSAIDs, opiates and gabapentin but the pain has now become so severe he states that he is unable to cope. He has previously been investigated for severe peripheral vascular disease and re-vascularisation of the affected limb is not possible. On examination he has a deeply erythematous right foot with dusky toes. Your consultant advises the patient that he requires a below knee amputation for Critical Limb Ischaemia, but is called away for an emergency. On leaving he asks you to consent the patient.
- Carotid endarterectomy under local anaesthesia
Stroke is the principle cause of neurological disability and the third commonest cause of death, after coronary disease and cancer, in the western world (Warlow CP 1993). Stroke is defined as acute loss of focal cerebral functions with symptoms exceeding 24 hours or leading to death. A transient ischaemic attack (TIA) is acute loss of focal cerebral functions with symptoms lasting less than 24 hours.
- History and techniques of aneurysm repair
Mr Johnson is a 70-year-old gentleman who has been referred by his GP to clinic with a 5.5cm seen on ultrasound scan. He is seen in clinic with the results of his latest USS aorta which shows the AAA to measure 5.5cm in max diameter. He is a hypertensive, well controlled on an ACE-inhibitor and an exsmoker. You discuss the options of surgical intervention with him.
- Lower limb amputation
A 68 year old gentleman with type II diabetes mellitus and a 50 pack year smoking history is admitted to hospital with severe rest pain in his left leg. He had a left femoro-popliteal bypass 12 months ago that has failed to improve his symptoms. His case is discussed at the Vascular Multidisciplinary Team meeting and it is decided that there are no further revascularization options available. The patient is listed for an above-knee amputation.
- Varicose veins
Varicose veins are dilated, tortuous subcutaneous veins that are >3mm in diameter when measured in the upright position. (1) In Western populations, the prevalence for varicose veins is >20% with an estimated 5% having associated signs of chronic venous insufficiency (CVI). Working in hospital or community, varicose veins and CVI will be encountered and the foundation doctor should have knowledge of their distribution, recognise complications such as skin damage and be aware of management options when advising or consenting patients. This case based discussion aims to cover aspects of good clinical care as stated in the foundation curriculum and update the reader on evidence based guidelines.
- Investigating peripheral vascular disease
This article focuses on the options available for investigation of peripheral vascular disease. It uses a common presenting case found in clinic to the decision-making process in choosing suitable investigations.
- The acutely ischaemic limb: assessment and mangement
Acute limb ischaemia is defined as a sudden decrease in limb perfusion that could threaten limb viability. It is a surgical emergency, which junior doctors may come across while on call. An outline of the clinical presentation, causes and a pragmatic way of assessing and managing acute limb ischaemia is illustrated in this article.
- Acute type B aortic dissection
A 71-year-old lady presented to the accident and emergency department with severe sternal chest pain radiating to the back and a cold pulseless left leg. A computer tomography scan confirmed a Type B aortic dissection (AD) with an occluded left external iliac artery. She underwent urgent thoracic endovascular aortic repair (TEVAR) with the placement of a stent graft, which restored blood flow to the true lumen. The patient suffered no post-operative complications.
- Assessment of an acutely ischemic limb
A seventy years old male patient was admitted to A&E with 2 hours history of acute pain in his left leg. This was a sudden onset sharp pain radiating down the leg and associated with paresthesia and weakness of left leg. His past medical history included type II diabetes, COPD and repair of abdominal aortic aneurysm 4 years ago. The patient appeared in severe pain and was dehydrated. Clinical examination revealed a cold, pale and painful leg with absent pulses on left side. The capillary refill was >5 seconds. The pulse rate was 98 beats per minute and was irregular. An ECG confirmed presence of atrial fibrillation and recent Myocardial infarction.
- Management of high cholesterol
This case based discussion focuses on the identification and management of patients with hypercholesterolaemia. The target groups for treatment are described, as are the options for conservative and pharmacological management.
- Taking an arterial blood gas
A 36 year old man, who is a known asthmatic, presents to the Accident and Emergency department with worsening shortness of breath and wheeze. He is tachypneoic, unable to complete sentences and has bilateral polyphonic wheeze on chest auscultation. What single investigation is required to appropriately diagnose and manage this patient?
- Central venous catheter insertion
Central venous catheter (CVC) placement is a useful adjunct in the monitoring and management of acutely unwell patients and those with poor venous access. This article reviews the indications for placement of a CVC, the technique for placement, possible complications and post procedure management.
- Paget Schroetter syndrome
The Paget-Schroetter syndrome is defined by acute primary thrombosis of the subclavian-axillary vein complex . It usually effects otherwise healthy young adults who present with acute swelling and cyanosis of the upper limb. Management can be complex and requires both initial treatment of the acute thrombosis as well as the correction of any underlying anatomical abnormality that has predisposed to the condition. Our case based discussion describes the presentation of an 18-year-old male with a subclavian-axillary venous thrombosis and focuses on the diagnosis and management of the Paget-Schroetter syndrome. It also highlights the importance of discussing treatment options fully with patients to allow them to make informed decisions about their treatment.
- Measuring the ankle-brachial pressure index
A 65 year old gentleman presented to the vascular clinic with a 3 month history of gradually worsening left leg pain which he says is brought on while walking but subsides if he stops and rests for a while. Over the preceding few weeks he has also noticed an area of ulceration over the dorsum of his foot which hasn't healed despite applying plasters and bandages. He is a smoker, moderately obese and also suffers from osteoarthritis, hypertension and is currently being investigated by his GP for a high blood glucose.
- Diagnosis of deep vein thrombosis in the leg
In this article, we discuss the clinical presentation and the current accepted method of diagnosis of deep vein thrombosis. Furthermore, we assess the different forms of imaging available and their relative advantages in diagnosing unusual manifestations of DVT.
- Surgery in the Jehovah's Witness
In this article, we have considered the Jehovah's Witness (JW) undergoing surgery. The pre-operative considerations, blood conservation techniques and post-operative care are discussed.
- Takotsubo cardiomyopathy: "broken heart syndrome"
This case based discussion focuses on a patient who presents with chest pain and was subsequently diagnosed with Takotsubo cardiomyopathy (TTC). Her classical clinical presentation throughout the clinical course illustrates a stepwise approach of the investigation, working diagnosis and treatment of this rare, newly recognised and potentially fatal syndrome. The aetiology and long term treatment of TTC are still under evaluation.