Acute medicine
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A 46-year old lady presented to the AMU with chest pain and shortness of breath. She weighed 345 kg. She was normally mobile up to 10 metres but had become bedbound over the past week with increasing shortness of breath.
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The utility of risk stratification following an emergency medical admission has been debated. We have examined the predictability of outcomes, from a database of all emergency admissions to St James' Hospital, Dublin, over a six year period (2005-2010). ⋯ A fractional polynomial laboratory only model can reliably predict 30-day hospital mortality following an emergency medical admission, potentially allowing resources to be risk focused and patients to be prioritised.
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Review Case Reports
Out with the old, in with the new? Case reports of the clinical features and acute management of two novel designer drugs.
Methoxydine (4-MeO-PCP) and Methoxetamine (3-MeO-2-Oxo-PCE) are both commercially produced designer drugs with structural and biochemical similarities to phencyclidine (PCP). Although phencyclidine toxicity is well documented, its recreational use in present times is rare. With the advent of new designer drugs being available widely through internet sites, Acute Physicians should be aware of the clinical features and management of these potential toxins. We present a case of methoxydine ingestion (which to our knowledge has not been previously documented in any medical journals) and a case of methoxetamine ingestion, and discuss their history, contrasting clinical features and acute management.
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Review Case Reports
Problem based review: the patient presenting with an acutely swollen arm.
A 69 year old female presented to the Emergency Department with swelling of her right arm and elbow, one week following a fall which resulted in a fracture of the middle third of her right clavicle (Figure 1). The forearm was hot and tender and the arm and hand function were somewhat impaired by swelling, but sensation was intact. Initial bloods were unremarkable, apart from a mild neutrophilia.
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The D-dimer assay's ability to exclude pulmonary thromboembolism (PTE) falls with age.1,2 Douma et al. have proposed an age-adjusted D-dimer threshold ([threshold, µg/l] = [age, years] x 10) for patients aged >50 years with low clinical risk of PTE.3 We retrospectively applied this threshold to patients who underwent computer tomographic pulmonary angiogram (CTPA) for suspected PTE during a 13 month period at a busy District General Hospital. Of the 423 patients >50 years old who underwent CTPA, 22 (5.2%) had D-dimer concentrations higher than the traditional threshold but lower than the age-adjust threshold, none of whom had evidence of PTE on CTPA. This suggests that use of the age-adjusted D-dimer threshold may reduce necessity for CTPA concept patients aged >50 years.