Acute medicine
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Acute hemiparesis is a common cause of presentation to hospital. In the majority of cases the cause is acute stroke, which is ischaemic in 80% of cases. This article aims to provide the reader with a practical approach to the initial management of suspected stroke. The problem-based format highlights some of the specific questions raised in the 2009 curriculum for training in Acute Internal Medicine, with reference to recent guidance from the National Institute for Health and Clinical Excellence (NICE).
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Chelsea and Westminster Hospital introduced the Chelsea Early Warning Score (CEWS) in 2007 to aid the recognition of acutely unwell patients. The Royal College of Physicians subsequently recommended a National Early Warning Score (NEWS) for implementation across the NHS. The aim of this study was to evaluate local adherence to CEWS to identify potential obstacles to the consistent implementation of NEWS. ⋯ Concerns highlighted with CEWS were the incomplete and inaccurate recording of aggregate scores, with underscoring resulting in the potential failure to recognise deteriorating patients. It is anticipated that NEWS will be accompanied by standardised documentation and training across the NHS which will support more complete and accurate recording of physiological data. Furthermore, NEWS appears from this study to be more sensitive than CEWS, thereby minimising the chance of missed deterioration.
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Unsafe patient transfers are one of the top reasons for incident reporting in hospitals. Criteria guiding safe transfer have been issued by the NHS Litigation Authority. To meet this standard, a "transfer check list" was redesigned for all patients leaving the Acute Medical Unit (AMU) in the Heartlands Hospital. ⋯ After interventions to educate nursing staff and raise awareness of the issues at the regular staff meetings, re-audit demonstrated significant improvement in completion rate. Subsequent monitoring indicates continued improvement, with compliance up to 95% for completion of the transfer checklist on AMU. Incident reporting relating to transfer has also decreased significantly.
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Euglycaemic ketoacidosis is a rare endocrine emergency, which can have disastrous consequences if left undiagnosed. We present the case of a 57 year old man with type 2 diabetes who developed ketoacidosis (DKA) following a myocardial infarction, despite being normoglycaemic, following discontinuation of his insulin infusion in an intensive care setting. The case highlights the importance of capillary ketone body testing in this scenario as well as the dangers of an over reliance on blood glucose values in the diagnosis of ketoacidosis. The notion that DKA can occur in both type 1 and type 2 diabetes is reaffirmed and the value of adequate insulin therapy in euglycaemic ketoacidosis is emphasized.