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.