Cover

Acute Medicine

CLINICAL CASES UNCOVERED

Chris Roseveare

BM FRCP

Consultant in Acute Medicine
Southampton University Hospitals NHS Trust
Southampton
UK

 

 

 

 

 

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For Tom and Matthew

Acknowledgements

Many people have assisted in the preparation of this manuscript and I will attempt to aknowledge all of these. Dr Ben Chadwick and Dr Stuart Henderson helped significantly in the writing of the chapters on the shocked and comatose patients; Dr Rebecca Strivens, Dr Nik Wennike, Dr Matt Todd, Dr Steven Hill and Dr Felicity Chastney also made very helpful contributions to the cases of chronic obstructive pulmonary disease, pyrexia, renal failure, seizure and the breathless elderly patient. I am also grateful to my colleagues, Dr Beata Brown, Dr Janet Butler, Dr Arthur Yue, Dr John Paisey, Professor Derek Bell and Dr Anindo Banerjee for reviewing some of the cases and for their helpful comments. I would also like to thank Dr Ivan Brown, Dr Harriet Joy and Dr Lynne Burgess in the radiology department at Southampton, for kindly providing radiographs for use in many of the cases.

Finally, I would like to thank my wife, Nicola, without whose patience and understanding I would not have been able to devote the necessary time to the production of this text.

How to use this book

Clinical Cases Uncovered (CCU) books are carefully designed to help supplement your clinical experience and assist with refreshing your memory when revising. Each book is divided into three sections: Part 1 Basics; Part 2 Cases; and Part 3 Self-assessment.

Part 1 gives you a quick reminder of the basic science, history and examination, and key diagnoses in the area. Part 2 contains many of the clinical presentations you would expect to see on the wards or in exams, with questions and answers leading you through each case. New information, such as test results, is revealed as events unfold and each case concludes with a handy case summary explaining the key points. Part 3 allows you to test your learning with several question styles (MCQs, EMQs and SAQs), each with a strong clinical focus.

Whether reading individually or working as part of a group, we hope you will enjoy using your CCU book. If you have any recommendations on how we could improve the series, please do let us know by contacting us at: medstudentuk@oxon.blackwellpublishing.com.

Disclaimer

CCU patients are designed to reflect real life, with their own reports of symptoms and concerns. Please note that all names used are entirely fictitious and any similarity to patients, alive or dead, is coincidental.

List of abbreviations

ABG          arterial blood gas
ACE          angiotensin-converting enzyme
ACS          acute coronary syndrome
AF          atrial fibrillation
ALP          alkaline phosphatase
ALT          alanine transaminase
ANA          anti-nuclear antibody
ANCA          anti-neutrophil cytoplasmic antibody
APTR          activated partial thromboplastin ratio
AST          aspartate transaminase
BBB          bundle branch block
BCT          broad complex tachycardia
BiPAP          biphasic positive airway pressure
CDU          clinical decision unit
COPD          chronic obstructive pulmonary disease
CPR          cardiopulmonary resucitation
CRP          C-reactive protein
CSF          cerebrospinal fluid
CT          computed tomography
CTPA          computed tomography pulmonary angiogram
CVP          central venous pressure
DIC          disseminated intravascular coagulation
DKA          diabetic ketoacidosis
DVT          deep vein thrombosis
EM          emergency medicine
ESR          erythrocyte sedimentation rate
EWS          early warning score
FBC          full blood count
FEV1          forced expiratory volume in 1 second
FVC          forced vital capacity
GCS          Glasgow Coma Score
GI          gastrointestinal
GTN          glyceryl trinitrate
Hb          haemoglobin
HDU          high-dependency unit
HPC          history of presenting complaint
IBD          inflammatory bowel disease
INR          international normalized ratio
JVP          jugular venous pressure
LFT          liver function tests
LMN          lower motor neurone
LMWH          low molecular weight heparin
LP          lumbar puncture
MI          myocardial infarction
NSAIDs          non-steroidal anti-inflammatory drugs
NSTEMI          non-ST elevation myocardial infarction
OGD          oesophagogastroduodenoscopy
OSCE          objective structured clinical examination
PA          posteroanterior
PCI          percutaneous coronary intervention
PE          pulmonary embolism
PEA          pulseless electrical activity
PEFR          peak expiratory flow rate
PND          paroxysmal nocturnal dyspnoea
PPI          proton pump inhibitor
PT          prothrombin time
PTP          pretest probability
REM          rapid eye movement
SAH          subarachnoid haemorrhage
SLE          systemic lupus erythematosus
STEMI          ST elevation myocardial infarction
SVT          supraventricular tachycardia
TGA          transient global amnesia
TIMI          thrombolysis in myocardial infarction
U&E          urea and electrolytes
VF          ventricular fibrillation
VT          ventricular tachycardia
WCC          white cell count

Preface

One of the attractions of acute medicine is the enormous variety of conditions which may present on the medical ‘take’. The nature with which these conditions can present is equally varied, although a large proportion of patients can be grouped into a much smaller number of common symptom ‘categories’. The curriculum for training in acute medicine (The Physicians of Tomorrow: Curriculum for General Internal Medicine (Acute Medicine). Federation of the Royal College of Physicians, London, 2006.) has identified 20 presenting symptoms which account for a large proportion of all emergency medical admissions (see Table I). Doctors undertaking training in hospital medicine are expected to attain competency in the management of all of these during their training.

The cases which are included in this book have been selected to illustrate the practical challenges which face clinicians involved with the initial management of acute medical patients. Most of the ‘Top 20’ presentations are included, with some minor modifications. Chest pain has been classified as ‘cardiac-type’ or ‘pleuritic’, since these two presentations usually require a different approach. Although patients do not usually use these terms when describing their symptoms, a referring clinician will often have categorised the patient’s pain in this way. ‘Breathlessness’ has been divided to illustrate the differences in the initial management of suspected acute asthma, exacerbation of COPD and undiagnosed breathless elderly patients. Acute confusion presents different diagnostic challenges in an elderly patient compared to a younger patient with alcohol dependency. Abdominal and back pain more commonly present to surgical and orthopaedic teams, and have therefore been omitted to enable inclusion of diabetic ketoacidosis and acute renal failure.

Clearly it is impossible to base a book on symptoms without considerable overlap between the cases. In order to avoid duplication, the reader will find frequent cross-references to different chapters where a condition is described in more detail. Some symptoms will require a broad differential diagnosis, while other conditions may present in a variety of ways. Myocardial infarction, for example, most commonly presents with ‘cardiac-type chest pain’, but may result in pleuritic-type pain, breathlessness, syncope or acute confusion. So-called ‘atypical’ presentations of common conditions are more common in elderly patients, where it is particularly important for the clinician to keep an open mind. Attempts to categorise the patient’s problem immediately on presentation may lead to the correct diagnosis being missed.

Table I ‘Top 20 presentations’ as defined in the Curriculum for General Internal Medicine (Acute Medicine)

Abdominal pain
Acute back pain
Blackout/collapse
Breathlessness
Chest pain
Confusion, acute
Cough
Diarrhoea
Falls
Fever
Fits/seizure
Haematemesis/melaena
Headache
Jaundice
Limb pain and swelling
Palpitations
Poisoning
Rash
Vomiting and nausea
Weakness and paralysis

This book is designed to provide readers with a ration-ale with which to approach patients presenting on the acute medical take. It is not possible to cover every condition or possible outcome, and this should not be considered a comprehensive reference text. More detailed information about some of the conditions can be found in Acute Medicine, 4th edition by D. Sprigings and J.B.Chambers (Blackwell Publishing, 2008), which can be used as an accompaniment to this text. References to the relevant sections in this book are included at the end of some cases, along with other useful sources of further information.

All of the cases in this book are entirely fictitious, but are based on an amalgamation of real patients presenting with similar symptoms; hopefully this has resulted in realistic scenarios similar to those which readers will face in their clinical practice.

Chris Roseveare

PART 1: BASICS

Introduction and specialty overview

What is acute medicine?

The term acute medicine has been a relatively recent addition to the UK healthcare vocabulary. In its 2007 document Acute medical care. The right person in the right setting – first time, the Royal College of Physicians defines acute medicine as:

that part of general (internal) medicine concerned with the immediate and early specialist management of adult patients suffering from a wide range of medical conditions who present to, or from within, hospitals requiring urgent or emergency care.

In short, acute medicine comprises the medical ‘take’ and its immediate aftermath.

Acute medicine: a brief history

Traditionally, responsibility for adult patients requiring admission to hospital, and whose care was deemed unlikely to require surgery (‘medical patients’), fell within the remit of the ‘general physician’. The increasing complexity of medicine over the last century led to the development of medical specialties, with specialty training programmes enabling physicians to acquire more detailed knowledge and skills in one area. However, most ‘specialists’ also maintained skills in general medicine (also termed general (internal) medicine, or G(I)M). This ensured that they were able to care for medical patients admitted to hospital as emergencies, or patients whose problem did not fall into a clear specialty category.

During the 1980s and 1990s, a number of challenges threatened to undermine traditional models of hospital care. A progressive increase in the number of medical patients admitted as emergencies was placing considerable pressure on hospital resources. In some cases this led to the cancellation of surgical procedures because of overspill of medical patients into other parts of the hospital; in other cases, patients were forced to spend prolonged periods of time waiting in corridors for a bed to become available. Alongside this pressure was a need to reduce the excessive hours worked by junior hospital doctors. One approach to address these challenges was the development of acute admissions wards (also termed ‘acute assessment wards’, ‘acute medical units’, ‘emergency admissions units’, etc.). This concept enabled the concentration of medical staffing resources in one area of the hospital, thereby reducing the numbers of junior doctors required to manage the emergency service. In addition, processes could be developed within these units to streamline the care of patients admitted as emergencies, preventing unnecessary admissions or reducing their length of stay in hospital.

However, despite the advantages provided by acute admissions wards, challenges persisted. Without clear medical leadership, many admissions units became dysfunctional ‘bottlenecks’ in the hospital. Many physicians were under pressure to provide a greater level of service to their specialty and wished to opt out of on-call and G(I)M. Additionally, much of the care of patients admitted as emergencies continued to be delivered by doctors in training, whereas patients demanded a consultant-led service. The concept of a specialty of acute medicine was first proposed by the Royal Colleges in 1998, since when the expansion of the field has been dramatic. The Royal College of Physicians has recommended that all hospitals should aim to appoint consultants specialising in acute medicine. Many hospitals now employ several specialist acute physicians, and a training curriculum in this field has existed since 2002. Acute medicine is currently the most rapidly expanding hospital specialty in the UK, and this trend is likely to continue over the next decade.

Acute medicine and emergency medicine

The development of the specialty of acute medicine has addressed many of the challenges around delivering care to medical patients admitted as emergencies. However, the interface between this field and the existing specialty of Emergency Medicine (EM) (previously termed Accident and Emergency) remains a subject of considerable debate. Although most of the first consultants in EM were from surgical or orthopaedic backgrounds, many of the patients presenting directly to hospital emergency departments (EDs) have medical problems that require ongoing inpatient care. This is now reflected in the training curriculum for EM, and consultants in EM are now expected to be skilled in the initial management of medical patients. Given the overlap between these two fields, some have challenged whether both specialties can survive as separate entities in the longer term.

However, there remain significant differences between these two specialties (see Table 1). Patients presenting themselves to the ED are entirely ‘unselected’. Emergency medicine consultants therefore have to be able to manage patients presenting to hospital with problems pertaining to any inpatient specialty, including paediatrics, obstetrics, surgery and trauma, as well as medicine. In addition, the main focus of the ED is usually the delivery of immediate care, identifying those patients who can be discharged and, for those requiring admission, ensuring stabilisation prior to referral to the appropriate specialty. By contrast, most of the patients seen by an acute medicine consultant will already have been seen by another clinician (either a GP or EM doctor) and deemed to have a ‘medical’ problem. Acute medicine specialists do not have the range of specialty knowledge of an EM specialist, although the depth of knowledge pertaining to patients with medical problems would normally be greater. Furthermore, acute medicine places more emphasis on continuing care and follow-up for medical patients, particularly those who do not fall into a clear medical specialty category.

Table 1 Differences between acute and emergency medicine

Emergency medicine          Acute medicine
Wide range of specialty skills including medicine, surgery, trauma, paediatrics          Medicine specific with greater depth of knowledge in this area
Patients self-present or brought by ambulance ‘999’          Patients usually referred by GPs or emergency medicine clinicians
Main focus is immediate care and management in first 4 h following presentation to hospital. A longer duration of stay may be feasible in some emergency departments with clinical decision units (CDU)          Greater focus on ongoing care and follow-up for medical patients, including ambulatory care

It is very likely that acute medicine and EM specialists will need to work in close collaboration in the future, to prevent unnecessary duplication of effort. Generic training programmes for acute specialties are already in existence and are likely to expand. The continued rise in the emergency workload will ensure that acute care of patients in hospital remains high on the UK healthcare agenda.

Models of care in acute medicine

Hospitals in the UK vary considerably in their size, structure and catchment population, resulting in a wide variation in the numbers of emergency medical admissions. This in turn will influence the model of acute medical service that is adopted by the hospital (see Table 2). Most larger hospitals will have an admissions ward, and many will have consultants with specific responsibility for this area. There will rarely be sufficient numbers of acute medicine consultants to provide a continuous service 24 hours a day, seven days per week; the service therefore usually relies on specialists with training in G(I)M to participate in an on-call rota. The Royal College of Physicians recommends that all patients are reviewed by a consultant within 24 hours of admission; in most cases this takes place during a ‘post-take ward round’. Depending on the number of admissions this process may occur one or more times each day. In some cases, consultants in acute medicine may adopt a more hands-on approach, providing ongoing review of patients admitted during daytime hours. However, most medical patients admitted as emergencies will usually be ‘clerked’ by a more junior member of the on-call medical team shortly after their arrival in hospital.

Table 2 Models of care in acute medicine

Model          Comments
On-call rota system          Traditional model where on-call consultant physician undertakes normal daytime commitments in their specialty followed by a ‘post-take’ ward round on the acute medicine unit at the end of this period
Physician of the day/week          Acute medicine service provided by physicians with other specialty interests, but specialty sessions are cancelled during their on-call day/week to enable provision of a more hands-on service
Acute medicine consultant          Specialist appointed specifically to provide part or all of the on-call service at consultant level. Large numbers are required to provide a comprehensive on-call rota so that a hybrid model with one of the other systems is usually adopted at present pending further expansion of specialist numbers

The development of skills relating to the initial assessment and management of patients admitted to hospital as medical emergencies is an essential component of training for all junior doctors. Students should take every available opportunity to develop these skills during their clinical years. Some of the essential skills required to work in this field are described in the next section.

Admission avoidance and acute medicine

Patients with medical problems are usually admitted to hospital for one of the following reasons.

• They require treatment which can only be delivered in a hospital environment

• They require investigation to confirm or refute a serious diagnosis that cannot be provided in an outpatient setting

• They are not able to care for themselves in the community because of combinations of medical and social problems

There are many reasons for the increase in hospital admissions in recent years; some of the most common are summarised below.

• Increased medical technology: treatments are now available (and often considered mandatory) for conditions that might previously have been managed in the community (e.g. stroke, myocardial infarction)

• Increased fear of litigation: the need to exclude significant pathology often requires a period of hospital assessment and investigation; conditions such as myocardial ischaemia, subarachnoid haemorrhage and meningitis may first present with relatively minor symptoms prior to life-threatening deterioration

• Increasing age of the population: older patients have greater medical and social needs, which can often not be met in the community

Much of the pressure to develop the specialty of acute medicine has centred around the need to prevent ‘unnecessary’ hospital admissions. Two of the strategies to deliver this are summarised below.

Risk stratification

Clinical features and targeted investigations can be used to produce a score that determines the likelihood of a condition or of an adverse outcome. Evidence-based risk scores for upper gastrointestinal bleeding (Rockall score, see Case 9), myocardial ischaemia (thrombolysis in myocardial infarction [TIMI] score, see Case 1) and pulmonary embolism (Wells score, see Case 2), are some of the best known.

It should be remembered that most scores continue to rely on a degree of subjective judgement, and should not be used in isolation. Senior clinical review is often required to support the use of this approach.

Ambulatory care

The term ambulatory care refers to the management of patients in an outpatient setting whose care would traditionally have required admission to a hospital bed. The service will often require a combination of rapid assessment, targeted investigation and treatment with regular review and follow-up. In many cases the setting for ambulatory care is within or adjacent to the acute medical unit, and specialist acute physicians are often responsible for the development and management of this service.

Examples of ambulatory care services include:

• Outpatient management of suspected and proven deep vein thrombosis, using daily injections of low molecular weight heparins (see Case 22)

• Daily provision of intravenous antibiotics for soft tissue infection (e.g. cellulitis)

• Supported early discharge of patients with chronic obstructive airways disease.

The precise model for such services may vary in different hospitals; however, access to the appropriate space, rapid diagnostic services and senior clinical review are essential components of ambulatory care.

Further reading

Department of Health. Emergency care ten years on: reforming emergency care. Professor Sir George Alberti. National Director of Emergency Access. DH, London, 2007

National Institute for Health and Clinical Excellence. Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. NICE clinical guideline 50. NICE, London, 2007

Royal College of Physicians. The interface between accident and emergency medicine and acute medicine. Report of a working party. RCP, London, 2002

Royal College of Physicians. Acute medicine: making it work for patients. A blueprint for organisation and training. Report of a working party. RCP, London, 2004

Royal College of Physicians. Acute medical care. The right person in the right setting – first time. Report of the Acute Medicine Task Force. RCP, London, 2007