Clinical medicine (London, England)
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Neurological emergencies represent 15-25% of the medical take, second only to cardiac and respiratory cases. However, the UK's number of neurologists is lower than that of other developed nations. This quality improvement project aimed to develop a guideline to optimise acute headache management by non-specialists, informed by the findings of a survey and audit of doctors' knowledge and practice. ⋯ A consultant neurologist deemed 14/27 (51.9%) of acute headache presentations audited pre-guidelines to have had appropriate management. After guideline launch, a re-audit demonstrated this proportion was 18/22 (81.8%) (p=0.04). We conclude the investigation and management of acute headache requires optimisation and a guideline may help to achieve this.
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Case Reports
Lesson of the month 2: A choroid plexus papilloma manifesting as anorexia nervosa in an adult.
A Caucasian female previously diagnosed with anorexia nervosa was referred by psychiatric services to the general medical team. She presented with dehydration, vomiting, weakness, a body mass index of 13 kg/m2 and was treated with intravenous and enteral supplementation. During admission her vomiting worsened and she developed visual hallucinations and confabulation. ⋯ Subsequent magnetic resonance imaging of the brain revealed a large fourth ventricular tumour causing obstructive hydrocephalus. The tumour was excised and histologically confirmed to be a choroid plexus papilloma. Postoperatively her neurological symptoms and negative feelings towards eating resolved.
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A 53-year-old woman was diagnosed with hypopituitarism following an acute presentation with cardiac tamponade and hyponatraemia, having recently been investigated for a pericardial effusion. Secondary hypothyroidism is a rare cause of pericardial effusion and tamponade, but an important differential to consider. ⋯ Clinical signs classically associated with cardiac tamponade are frequently absent in cases of tamponade due to primary and secondary hypothyroidism, and the relatively volume deplete state of secondary hypoadrenalism in hypopituitarism may further mask an evolving tamponade, as the rise in right atrial pressure is less marked even in the presence of large effusion. Our case demonstrates the importance of a high index of suspicion for cardiac tamponade in this patient cohort, even in the absence of clinical signs, and for measuring both thyroid-stimulating hormone and thyroxine levels when evaluating a pericardial effusion.
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Reform of physician education is needed to meet the needs of patients, based on comorbidities, chronic disease management and complexity. The Joint Royal Colleges of Physicians Training Board has developed a new internal medicine curriculum for physician training that aims to not only deliver this expectation, but will simplify competency-based education, smooth the transition to the medical registrar role and hopefully fill some of the current empty funded training posts. However, the change process is complex and requires close working with the General Medical Council and other partners in curriculum delivery.