Clinical medicine (London, England)
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Cytomegalovirus (CMV) is a ubiquitous pathogen, belongs to the herpes virus family and can infect the gastrointestinal (GI) system. The disease is usually noted in immunocompromised patients such as solid organ transplant recipients on immunosuppressive drugs, patients with malignancy receiving chemotherapy, patients with AIDS, patients on steroids for autoimmune disorders, and is rarely seen in immunocompetent individuals. ⋯ Very rarely, CMV infection may present with a massive GI bleed. We report a case of 36-year-old pregnant woman with idiopathic thrombocytopenic purpura (ITP) who presented with massive GI bleeding following delivery, attributed to isolated CMV enteritis.
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Hypercalcaemia is a common electrolyte abnormality with 90% of cases due to either primary hyperparathyroidism or malignancy. Other causes of hypercalcaemia often require careful consideration. ⋯ This approach is illustrated by a case which posed a diagnostic challenge: a patient with significant hypercalcaemia due to acute atypical isolated sarcoid myositis. This case highlights an under-recognised clinical syndrome with distinct biochemical and radiological findings.
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Mechanical thrombectomy is a highly effective but time dependent treatment for acute ischaemic stroke due to large vessel occlusion. In the UK, the national clinical guidelines for stroke and National Institute for Health and Care Excellence guidance endorses thrombectomy as an acute stroke treatment, and NHS England commissioned thrombectomy services. However, there are no UK 'real-world' data to verify the efficacy of the hub-and-spoke model in thrombectomy. ⋯ Fifty-three per cent of thrombectomy cases were performed outside of standard working hours when transfer delays were increased. A 24/7 thrombectomy service is needed to maximise the benefit to all suitable patients. Measures, including improving workflow and optimising work forces, are needed to minimise the delays and continue to improve the service.
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Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles.
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Normal baseline investigation results in a patient with common symptoms is often labelled as being due to a functional disorder, with all the pejorative connotations that go along with that term. When given the opportunity to see a patient for a second opinion, it is important to retain an open mind rather than assuming previous assessments are correct. Such an attitude helps with both attaining the definitive diagnosis but is also crucial to helping give hope to the patient. Understanding the patient's concerns about the meaning of their symptoms is critical in finding the balance between advanced investigation to identify a putative cause versus a decision to proceed with symptomatic control.