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It is well established that acute renal failure is associated with a significant increase in mortality, but over recent years it has become apparent that even relatively small rises in serum creatinine are associated with adverse patient outcomes. The term acute kidney injury (AKI) was developed to reflect this broader spectrum of renal injury, ranging from patients with small changes in blood chemistry...
The optimal use of laboratory tests requires an understanding of the many variables that may influence the result and its interpretation. This is especially important with the increasing use of point-of-care testing. In this article we cover how to request the ‘right test’ as well as some of the variables. Most common tests are discussed.
Falls in older people are very common and for some the consequences can be devastating. The clinical assessment, management and investigation of patients who present with falls can be challenging for the non-specialist, and multiple guidelines and algorithms have been published to aid that process. This article has been prepared as a concise reference that reviews the most recent evidence and covers...
Biomarkers represent a major technological innovation in medicine. This article discusses the definition and uses of biomarkers, particularly their role in diagnosis, risk stratification and management of disease. It reviews the current roles of the seven most commonly used biomarkers in the acute setting (troponin, creatine kinase, brain natriuretic peptide, d-dimer, C-reactive protein and procalcitonin)...
Epileptic seizures are common, and patients suffering a first seizure are often admitted to hospital as an emergency. Differentiating epileptic seizures from other types of attack can be difficult, and misdiagnosis has potentially serious consequences for the patient. Knowledge of the clinical features of epileptic seizures and what distinguishes them from dissociative (psychogenic) seizures, syncope...
Acute anaphylaxis has been described as ‘a serious allergic reaction that is rapid in onset and may cause death’. It is becoming more common and is underdiagnosed. Even when anaphylaxis is recognized, it tends to be undertreated. In view of these factors, all clinical staff should maintain awareness of it in order to recognize, assess and manage it optimally. In this article we have concentrated equally...
Headache is very common and affects almost everyone at some point. Most patients have primary headache and present non-acutely to their general practitioner (GP). A small proportion will, however, present acutely, either directly to the emergency department or to acute medical units (AMU) via their GP. A significant proportion of these patients will have a serious cause for their headache. It is the...
Limb pain and swelling is one of the ‘Top 20’ presentations in acute medicine. Patients present mainly with lower limb signs and symptoms, but upper limb presentations also occur and should be investigated and managed in a similar way. The causes can be divided into those producing bilateral changes, including fluid overload from cardiac or renal failure, low serum albumin or dependency oedema due...
Chest radiography is the most commonly performed diagnostic imaging test, but in unselected acute medical admissions it offers low diagnostic yield and high case-finding costs. There has been a trend towards the use of targeted radiological investigation. Advances in computed tomography technology, with improvements in spatial and temporal resolution, have facilitated detailed cardio-pulmonary imaging...
Confusion and delirium are the most common behavioural disorders seen in an acute medical or surgical unit. Confusion can be regarded as a mild form of delirium and may give warning of the development of the more severe disorder. It causes an acute change of mental status, characterized by abnormal and fluctuating attention. It affects between 10 and 30% of medically ill patients, especially the elderly...
The unconscious patient is a medical emergency which can challenge the diagnostic and management skills of any clinician. A systematic and logical approach is necessary to make the correct diagnosis; the broad diagnostic categories being neurological, metabolic, diffuse physiological dysfunction and functional. Even when the diagnosis is not immediately clear, appropriate measures to resuscitate,...
Acute stroke and transient ischaemic attack (TIA) are focal neurological syndromes of vascular origin and should be treated as medical emergencies. Brain imaging with computed tomography or magnetic resonance imaging is required to identify ischaemia from haemorrhage, recognize non-stroke pathologies that mimic stroke and guide investigation for underlying mechanism. Acute interventions of benefit...
Management of poisoning involves the assessment and treatment of airway compromise, ventilation impairment and haemodynamic instability. Thereafter, temperature disturbances should be treated, convulsions controlled, fluid, acid–base and electrolyte abnormalities corrected, and complications such as methaemoglobinaemia, rhabdomyolysis and serotonin syndrome diagnosed and managed optimally. There is...
Back pain will affect 60–80% of the population in industrialized countries. The majority of back pain (90%) will settle in 6 weeks. For most patients, keeping active and optimal pain control with regular simple analgesics will suffice. This article describes how to identify ‘red flags’ indicative of serious spinal pathology in patients with back pain, how to assess for markers of chronicity (‘yellow...
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