INTERESTING CASES IN ACUTE MEDICINE
Mr Ravi Potdar
Dr Tariq Memon
Dr Amit Badshah
CASE 1
18 year Female
Presenting complaints :
Feeling unwell for last 2/12.
Previously High BMI – now progressive unintentional weight loss.
No access to any weight loss drugs.
No c/o any infective symptoms.
No h/o any red flags of malignancy
FURTHER HISTORY
• Recent break up with Boyfriend
• H/o feeling unwell coincided with relationship
issues
• Mum reported – manipulative about food.
• Pretend to eat but hides food and throws away.
CASE 1
• PMH
No previous psychiatric history or eating disorder
• Drug history
OCP
CASE 1
CLINICAL EXAMINATION
• Cachectic look, clinically dehydrated, normal dentition, no evidence
of dental caries.
• HR – 128 - regular, low volume, BP- 70/43, Afebrile
• CVS – NAD
• Neuro – GCS 15/15, No focal neurology
• Resp – NAD
CASE 1
DIFFERENTIAL DIAGNOSIS
• Hypovolemia – dehydration
• Eating Disorder
• Underlying depression
• Sepsis
CASE 1
INVESTIGATIONS
• CXR – NAD
• ECG – Sinus tachycardia
• Urine and BHCG – NAD
Hb WBC CRP Creatinine Urea Na+/K+ Ca2+ Glucose
118 6.6 11 108 11.1 134/5.5 3.04 2.8
Hyponatraemia and Hypercalcemia
CASE 1
MANAGEMENT
• IV Fluids – received up to 9 litres in 48 hrs with good urine output
• 10 % Dextrose
• Pabrinex for nutritional supplements
• Psych review planned
• Effect of treatment – remained hypotensive and tachycardiac with no
improvement in clinical condition.
• Seen by ITU Outreach team - ? For Inotrops
CASE 1
53 Year female
• Presented with D+V for 7/7 and progressive weight loss
• Loose watery diarrhoea – no blood or mucus
• Recent travel to Spain ( 10/7 ago )
• No h/o fever, abdominal pain or urinary symptoms
• Weight loss – for last 3 months with anorexia
• No B symptoms
• No h/o chest symptoms or altered bowel habits
CASE 2
CASE 2
• PMH: Hypothyroidism, Vitiligo, Psoriasis, Anxiety
• Medications : Levothyroxine 100mcg od, Mirtazapine
• Social : Independent, lives with family
• Family history : None significant
CLINICAL EXAMINATION
• Tanned skin – recent trip to Spain, clinically dehydrated
• BP- 60/40, HR – 120 regular, Afebrile
• CVS – NAD
• RESP- NAD
• Neuro- GCS 15/15, No FND
• Abdomen – SNT – No organomegaly
CASE 2
DIFFERENTIAL DIAGNOSIS
• Sepsis
• Travellers diarrhoea
• Thyrotoxicosis
• Occult Malignancy
CASE 2
INVESTIGATIONS
• CXR- NAD
• AXR – NAD
• Urine – NAD
• Stool – norovirus positive ( on 2nd day )
O/A Hb WBC CRP Creatinine/Urea Na+/K+ Calcium
166 15.1 157 328/6.9 126/5.1 2.93
AKI Stage 2
Hyponatremia and Hypercalcemia
CASE 2
MANAGEMENT
Day 1 to 3
• ITU Admission – due to persistent hypotension and sepsis
• IV Abx – Tazocin
• IV Fluids – 5 lits in ED/ITU – No improvement in BP
• IV Metaraminol – ( Inotrops)
• CT Aortogram – ( done in ITU) no dissection
CASE 2
MANAGEMENT
Day 3 to 5
• loose stools settled
• AKI Resolving
• Infection settled
However
Pt remained hypotensive and unwell
CASE 2
ADDISON’S DISEASE
ADDISON’S DISEASE
Long-term endocrine disorder in which the adrenal glands
do not produce enough steroid hormones +/- mineralocorticoids
ADDISON’S DISEASE
ADDISON’S DISEASE
INCIDENCE
• Rare endocrine disorder.
• Affects 1:100,000.
• Affects all age groups.
• Affects equally both male and female.
ADDISON’S DISEASE
CAUSES
Autoimmune – 80% cases (more in female)
Infection
• Tuberculosis - 10%
• Bilateral adrenal haemorrhages due meningococcal septicaemia
( Waterhouse- Friedrichson Syndrome)
ADDISON’S DISEASE
CAUSES
Infiltrations
• Amyloidosis.
• Sarcoidosis
• Haemochrmatosis.
• Lymphoma.
• Secondary deposits in adrenal gland.
ADDISON’S DISEASE
CLINICAL FEATURES
Weight loss.
Anorexia.
Weakness.
Nausea
Vomiting.
Postural hypotension.
Shock.
Hypoglycaemia.
Hyponatraemia.
Hyperkalaemia.
Hypercalcaemia.
Hyperpigmentation.
ADDISON’S DISEASE
INVESTIGATION
• Random plasma Cortisol.
• SST ( Short Synchten Test)
• FBC ( Pernicious Anaemia)
• Blood glucose.
• Electrolytes including Calcium Level
• HIV
• Adrenal Auto antibodies.
• CXR
• CT Adrenals.
ADDISON’S DISEASE
MEDICAL TREATMENT
• Replacement of glucocorticoid hormone.
• Normal physiological requirement 20mg per days in
divided doses.
• Treatment of cause.
• If symptomatic postural hypotension despite
physiological dose of glucocorticoid hormone then
consider mineralocorticoid ( Fludrocortisone 50-
100mcg).
ADDISON’S DISEASE
TREATMENT(PATIENT EDUCATION)
• Bracelet.
• Steroid card.
• Side effects of glucocorticoid excess.
ADDISON’S DISEASE
Sick day rule 1 Double your usual dose of steroids during:
a. Periods of illness with fever, or
b. Illness requiring bedrest; or
c. illness requiring treatment with antibiotics
Sick day rule 2 Inject hydrocortisone intramuscularly
subcutaneously, intravenously( In hospital )
during:
a. periods of severe illness;
b. persistent vomiting or diarrhoea;
C. fasting (absence of food or drink)
Patient Education ADDISON’S DISEASE
Surgery requiring general
anaesthesia
inform your endocrinologist
before surgery so that proper
advice can be given to your
surgeon/doctor.
Before major physical
activity(long distance running, marathon,
or major sports activity)
might benefit from taking a
small dose of extra steroid
e.g.2.5-5 mg of
hydrocortisone
Pregnancy D/W Endocrinologist
Sick day rule
ADDISON’S DISEASE
COMPLICATIONS
• Cardiovascular collapse.
• Coma.
• Death.
ADDISON’S DISEASE
FOLLOW UP
Endocrine team
• History :
Mood disturbance, visual disturbance
(Cataract),wasting & weakness of proximal
thigh muscles and urine test for glucose.
• Examination:
Check blood pressure, body weight, oedema
& height (axial spine demineralisation and
compression).
ADDISON’S DISEASE
CASE REVIEW
Progressive unintentional weight loss
Persistent hypotension
Similar electrolyte imbalance –
low Na+, high K+, high Ca2+.
SHORT SYNACTHEN TEST : SST
Case 1 Case 2
Give IV ACTH 250mcg : Check cortisol 0” , 30” , 60”
Normal response : cortisol rises > 400
0 Min 17
30 Min 19
60 Min 25
0 min 60
30 min 63
60 min 66
HYPERPIGMENTATION
TAKE HOME MESSAGE
Persistent hypotension despite fluid resuscitation and other
appropriate measures !!!!!!!!
Hyponatremia with hyperkalaemia.
Think Addison’s
Known Addison's -- in unwell patients
Think Crisis
Double the dose of regular steroids or IV Hydrocortisone
Any Questions ???
ADHERENCE TO NICE GUIDELINES IN DIAGNOSIS OF PE IN DGH
Dr Amit Badshah
Dr Tariq Memon
Ravi Potdar
PULMONARY EMBOLISM
Serious condition needs prompt assessment, diagnosis and management.
OBJECTIVE
• To determine compliance rates with NICE guidance 144, and
offer guidance if necessary
AUDIT STANDARDS
NICE guideline 144
• If a patient presents with signs or symptoms of
pulmonary embolism (PE), carry out an assessment
of their general medical history, a physical
examination and a chest X-ray to exclude other
causes. [2012]
• If PE is suspected, use the two-level PE Wells score
to estimate the clinical probability of PE. [2012]
TWO LEVEL PE WELLS SCORE
METHOD
• 100 patients : who had CTPA
• Symptoms
• Investigations
• Wells score
CLINICAL FEATURES OF PE IN DESCENDING ORDER
(ACCORDING TO NICE )
• Dyspnoea (70% of patients).
• Tachypnoea (RR >20).
• Pleuritic CP.
• Apprehension.
• Tachycardia (HR >100).
• Cough.
• Haemoptysis.
• Leg Pain.
• Clinical evidence of DVT (10% of patients)
CLINICAL FEATURES
0
10
20
30
40
50
60
70
80
Presenting complaints of those who had CTPA
• Majority of patients presented with mix symptoms.
• Good History and clinical examination are key
factors in order to establish the diagnosis followed
by appropriate investigation depending on risk
stratification.
WELLS SCORE RECORDED
3
97
Yes
No
INCIDENCE OF PULMONARY EMBOLISM
14
86
RESULTS
• It was expected that all patients should have had Wells Score
recorded
• Only 3% been recorded
• 14% actually had PE
OUTCOME
• Difficult to know how many warranted CTPA
• Can assume unnecessary CTPAs have been performed
• Poor compliance with NICE guidelines.
• CTPA = 350 CXR
• Costly investigation
SUGGESTIONS FOR IMPROVEMENT
• This data has been presented at the grand round.
• Clerking team have been encouraged to document wells score
in all patients with suspected PE.
• Discussion with radiologists – Mandatory Wells score in the
CTPA request
• Will re-audit following these implementations.
THANK YOU!
REFERENCES
1. NICE clinical guidance 144
2. Worsley DF, Alavi A. Comprehensive analysis of the results
of the PIOPED Study. Prospective Investigation of
Pulmonary Embolism Diagnosis Study. J Nucl Med. 1995
Dec. 36(12):2380-7.