I thought that things were looking very Autumnal today when I was in Aberfoyle today - hence the reason for the photo.
Interesting articles which I've been reading this week in the BMJ:
Adrenal Crisis - Since I've been revising endocrinology today for the MRCP, this article was particularly relevant. There are two serious hormone deficiency syndromes which if left untreated can be fatal. Everyone knows about the first one - diabetic ketoacidosis, but a lot less is known about acute adrenocortical insufficiency. This requires urgent treatment with hydrocortisone, IV fluids and correction of biochemical abnormalities. If steroids are stopped in patients on long term steroid treatment (Addisons Disease) or during periods of increased stress / illness, a crisis can occur. Clinical features include hypotension, shock, hyponatraemia and hyperkalaemia. One trick is to never ignore an informed patient's request for steroids. Chances are that they have Addisons Disease and are aware of the consequences of under-treatment. Peri-operative is also a dangerous time for patients with Addisons Disease if they are not being correctly managed. Adrenal crisis is regularly seen in patients with congenital adrenal hyperplasia as they are unable to mount a normal cortical response to stress. Adrenal crisis has been reported in patients on high doses of topical steroids. Patients on steroids should carry a 'Medic-Alert' card or bracelet. Doctors must not suddenly stop steroid treatment in patients who are admitted to hospital. Ideally a 'Red-Flag' system needs to be identified to alert staff when these patients are admitted.
Chocolate at the Checkout - In most shops when you get to the check out there is an array of tasty treats awaiting the consumer. Who hasn't picked up the odd chocolate bar or drink at the check-out!? The public health team have picked up on this and are suggesting that such sales technique should be removed to stop tempting people. Impulse buys are particularly common when patients are tired and stressed. Maybe we should put chocolate bars in special locked cupboard behind the counter (like cigarettes) if that's the case! I don't think that the supermarkets and shops are going to change their marketing techniques very quickly on this one but any idea is worth pursuing to help reduce the growing incidence of obesity in the UK.
Discouraging Health Checks - It seems like a good idea. 'Free health checks to all'. A definite political winner. However a review of 16 large trials of health checks to asymptomatic adults aged 40-74 found that checks were unlikely to save any lives. The problem with this I think is that it's always the healthy people who are the ones coming forward for these checks. These are not the people that need to be targeted in this type of public health campaign. How to engage the people who really need checks is the golden question which public health researchers are going to be forever scratching their heads about.
Swollen Leg in the Middle of the Night - Finally, this appeared in the 'Picture Quiz' section of the BMJ and just serves as a reminder of the importance of clinical examination and considering a differential diagnosis when the symptoms and signs just don't quite match up with what you're thinking about.
A doctor reviews a 47 year old man in the night who is complaining of leg pain and swelling of his right thigh. The doctor diagnoses a DVT and heparin treatment is started, pending a Doppler ultra-sound scan to confirm the diagnosis. Examination isn't documented. A few hours later the patient is in agony and a second doctor comes to review. The patient now has cool peripheries, tachycardia, hypothermia and an area of violaceous discolouration on his thigh. An X-ray is performed, and the findings are in keeping with necrotising fasciitis (caused by a Clostridium sp. bacteria in this case). Urgent fluid resuscitation, transfer to HDU, broad spectrum antibiotics and surgical debridement is required.
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