Medicine

2009-01-01

Editorial Board

2009-01-01

Cardiorespiratory arrest

Clive Weston — 2009-01-01

Abstract: During core medical training the trainee should acquire sufficient knowledge and skills, and demonstrate appropriate attitudes and behaviours to allow the competent assessment and resuscitation of patients who have suffered cardiorespiratory arrest. These attributes have been defined by the UK Resuscitation Council, whose most recent guidelines are based upon an extensive systematic review of evidence by teams of international experts.

Shock

Kenwyn James, Max Jonas — 2009-01-01

Abstract: Shock is a frequently misused and misunderstood term. When used to describe the process of tissue hypoperfusion, leading to cellular hypoxia and organ failure, it describes a medical emergency with a high mortality. Early recognition of the condition and prompt, appropriate management is essential to increase survival. This includes timely use of appropriate monitoring including clinical signs, biochemical tests, and invasive pressure and flow monitoring. In carefully selected patients, measurement and manipulation of oxygen delivery has been shown to improve outcome. Rapid identification of the underlying cause and definitive treatment are needed to reduce morbidity and mortality. In the clinical scenario of septic shock, early antibiotics are vital. Every hour’s delay in the administration of appropriate antibiotics is associated with approximately an 8% decrease in survival.

The clinical evaluation of abdominal pain in adults

Mathena V. Pavan, Gautam Mehta, Andrew V. Thillainayagam — 2009-01-01

Abstract: Abdominal pain represents a diagnostic and therapeutic challenge for the gastroenterologist and the general physician. An accurate history and diagnostic framework are essential to ensure that serious physical illness is not missed, and that psychological causes of abdominal pain are not reinforced by excessive investigation. Understanding of the pathophysiology of abdominal pain, and its common presentations, allows the skilled physician to quickly establish the diagnosis. Visceral pain is typically poorly localized, unlike somatic pain, which is well localized and sharp in nature, typically reflecting inflammation of the pleura, peritoneum or diaphragm. Referred pain is felt distant from the affected organ due to activation of dermatomal somatic nerves. This article focuses on the diagnosis and management of acute abdominal pain, and explains common presentations, including hepatobiliary, epigastric, pancreatic and lower abdominal pain. Although in most cases this diagnostic approach will provide the physician with the likely diagnosis, there are several groups of patients, including the elderly and immunosuppressed, in whom this approach is inadequate. By being alert to the atypical presentations described, these challenging patients can be successfully managed.

Acute back pain

Jennifer Hamilton — 2009-01-01

Abstract: Back pain will affect 60–80% of the population in industrialized countries. The majority of back pain (90%) will settle in 6 weeks. For the majority of patients, keeping active and optimization of analgesia using regular simple analgesic agents will suffice. This article describes how to identify back pain red flags, indicative of serious spinal pathology, how to assess for markers of chronicity (yellow flags) and when to refer for further investigation and specialist input.

Diarrhoea

Kinesh Patel, Andrew V. Thillainayagam — 2009-01-01

Abstract: Disturbances in bowel habit are frequent occurrences in both the developed and developing world: their onset often prompts patients to seek medical attention. The causes of diarrhoea are myriad, ranging from the benign and self-limiting to the life-threatening. A careful history and examination are vital when managing patients presenting with diarrhoea. Further testing, which is often invasive and uncomfortable, should be reserved for those patients with worrying clinical features. Treatment of acute diarrhoea is often supportive; for those with chronic symptoms, treatment is usually aimed at the underlying cause.

Fever

Chantal P. Bleeker-Rovers, Jos W.M. van der Meer, Nick J. Beeching — 2009-01-01

Abstract: Fever results from a rise in the hypothalamic set point due to an elevation of prostaglandin E2 in the brain as a result of an increased synthesis of this substance caused by exogenous pyrogens and pyrogenic cytokines. Patients with acute fever should be promptly assessed for signs of sepsis. Pyrexia of unknown origin (PUO) is defined as a fever higher than 38.3 °C on several occasions during at least 3 weeks, with uncertain diagnosis after a number of obligatory tests. No diagnosis is reached in up to 50% of cases. A diagnostic algorithm is proposed in which the most important steps are history-taking, physical examination and the obligatory investigations in a search for potentially diagnostic clues (PDCs). Scintigraphic methods, such as 67gallium citrate, labelled leukocytes and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), are often used in PUO. Because of favourable characteristics of FDG-PET, conventional scintigraphic techniques may be replaced by FDG-PET in institutions where PET is available. Most patients with undiagnosed PUO have benign self-limiting or recurrent fever.

Haematemesis and melaena

Kelvin Palmer — 2009-01-01

Abstract: Acute gastrointestinal bleeding remains an important medical emergency. Outcome and treatment are influenced by the presence or absence of liver disease. The most important non-variceal cause is peptic ulcer. Prognosis is dependent upon the severity of bleeding, endoscopic findings and the presence of medical co-morbidity. Endoscopy is undertaken only after resuscitation is optimized and is done to achieve an accurate diagnosis, provide prognostic information and effect haemostasis by combinations of injection, cauterization or application of clips. High-dose acid-suppressing drug therapy is used in endoscopically treated patients to reduce the risk of re-bleeding and need for surgical intervention. Operative surgery is required when endoscopic haemostasis cannot be achieved. The prognosis of patients presenting with variceal bleeding is directly related to the severity of liver disease. Early endoscopy is done after initial resuscitation and oesophageal varices are treated by band ligation or sclerosant injection. Antibiotic therapy improves mortality whilst vasopressin analogues have a limited adjunctive role. Other aspects of liver failure (hepatic encephalopathy, renal failure and fluid retention) require specific treatment. Failures of endoscopic and pharmacological therapies are treated by transjugular intrahepatic porta-systemic shunt or occasionally by porta-caval shunt surgery.

Jaundice

Ian Gilmore, Conall J. Garvey — 2009-01-01

Abstract: Jaundice is the result of accumulation of bilirubin in plasma, sometimes from its overproduction from senescent erythrocytes but more usually through failure of the liver to either remove it from plasma or excrete it into the intestine via the bile ducts. Overproduction (haemolysis) or reduced conjugation through a defective UDP-glucuronyl transferase in Gilbert’s syndrome results in modest elevations of unconjugated bilirubin (<100 μmol/litre) and absent bile in urine. Liver disease and extrahepatic obstruction result in conjugated jaundice with dark urine. With modern imaging, initially transabdominal ultrasound, it is usually possible to identify extrahepatic obstruction, particularly from malignancy, but bile duct stones may be difficult to visualize and may not cause much duct dilatation. Spiral computed tomography, endoscopic ultrasound and magnetic resonance scanning with computerized reconstruction of the cholangiogram almost always resolve uncertainties about extrahepatic obstruction. The more invasive endoscopic retrograde cholangiopancreatography can be reserved for therapeutic interventions such as sphincterotomy and removal of bile duct stones. Where there is no extrahepatic cause of jaundice, it may be an important presentation of liver failure, both acute and chronic, and careful attention should be paid to features of deteriorating liver function that might require specialist care.

Rash

Shalini Narayan — 2009-01-01

Abstract: In order to make an accurate dermatological diagnosis, firstly a thorough history needs to be taken, followed by a full skin examination of the patient, including examination of the scalp, nails and sometimes mucosae. Usually this will lead to the correct diagnosis, but sometimes additional investigations are needed to aid the clinician. This article looks at ways of assessing the dermatology patient by taking a thorough history and examination, and using appropriate investigative tools when needed. It discusses the use of appropriate dermatology terminology when describing rashes, presentations of some common acute, chronic and infective rashes, and appropriate treatments for some of the more common dermatoses.

Tropical medicine

Anthony W. Solomon, Shevanthi Nayagam, Geoffrey Pasvol — 2009-01-01

Possibly the most relevant new concept in tropical medicine is how our perception of the subject has changed in the last few years from the days of classical descriptions of parasitology, infectious agents and entomology. Some now prefer to use the term ‘International Health’, emphasizing that with the advent of the Internet, rapid international travel and communication, we have now become part of the ‘Global Village’. Tropical medicine is an issue that we, in the wider world, can no longer afford to neglect: progress in this field continues in leaps and bounds.

Self-assessment/CPD

2009-01-01

Medicine

Contents

Editorial Board

Cardiorespiratory arrest

Shock

The clinical evaluation of abdominal pain in adults

Acute back pain

Diarrhoea

Fever

Haematemesis and melaena

Jaundice

Rash

Tropical medicine

Self-assessment/CPD