4

Four Lists of Ten

This chapter contains four tables showing what I think are the ten most important emergencies, the ten most common presenting complaints (in hospital), the ten most useful tests and the ten most useful drugs. This section is as brief as it gets. We have seen virtually everything in these tables before, in one way or another. Like every section of this book, these tables are very far from exhaustive, but they represent the key core areas that I think should be the fundamentals of your knowledge. In the learning of medicine, emphasis is placed on conditions that are common, life-threatening and curable. Not that many conditions are truly curable (most infections, some cancers possibly), but a great deal of illnesses are least in some way treatable. It is such conditions that are dealt with here.

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124 Chapter 4

4.1. THE TEN MOST IMPORTANT EMERGENCIES

The table (Table 4.1) shows what I consider to be ten important emergencies that you need to know about. We are not going to consider the ultimate emergency, cardiac arrest. Ventricular tachycardia is a cardiac arrhythmia one step short of ventricular fibrillation. It is usually a complication of ischaemic heart disease. The ventricles take it upon themselves to beat at a mechanically-inefficient rate of 180200, at which rate the heart only just sustains an output. It can be treated pharmacologically, but often a DC shock is required to reset the heart. Raised intracranial pressure is discussed in Section 2.7.2.8. Very severe asthma and very severe epilepsy, also known as status asthmaticus and status epilepticus respectively, are conditions in which asthma and epilepsy become life-threatening. The asthmatic lung is very tight, so tight that the breath sounds may be almost inaudible; the patient is blue and drowsy with a fast, thready pulse. In severe epilepsy, one fit is closely followed by another, and then another, etc. This anoxic cycle must be interrupted. Acute pulmonary oedema is a very urgent form of (left) heart failure (Section 2.1). Tension pneumothorax occurs when air can get out of the lung into the pleural cavity but not back again, so that the air builds up in the pleural cavity, taking up more and more space, and compressing both of the lungs and the heart. The key signs are absence of breath sounds on the affected side (which must be resonant to percussion), and deviation of the trachea to the opposite side. Diabetic ketoacidosis is the metabolic acidosis that occurs in the absence of insulin. A hyperventilating, acidotic patient; ketones in the urine. Temporal arteritis is a large vessel vasculitis in older people that goes for the head and neck. It can affect the central retinal arteries, giving sudden irreversible blindness. It responds quickly to steroids.

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Four Lists of Ten 125 Table 4.1. The Ten Most Important Emergencies. State 1 Ventricular tachycardia 2 Raised intracranial pressure 3 Very severe asthma Clinical Rapid, thready, regular pulse. Hypotensive. Nauseated, vomiting, drowsy, dilated pupils, papilloedema, IIIrd, VIth palsies. Essential Tests ECG. Action DC shock. Amiodarone. MgSO4. Dexamethasone, sometimes surgery if needs be. O2, nebulisers, steroids, ventilate.

CT head.

Collapsed, blue, CXR, gases, try dyspnoeic, widespread to record polyphonic rhonchi, peak flow. silent chest. Recurrent fits.

4 Very severe epilepsy

Blood glucose, U&E, Diazepam; often drug levels if paralyse and relevant. ventilate. O2, morphine, diuretics, IV GTN.

5 Acute pulmonary Cold, sweaty, very CXR. oedema dyspnoeic. Pink, frothy ECG. sputum. Masses of medium crackles in all lung fields. 6 GI bleed Haematemesis, melaena, Endoscope. low BP, postural fall, PTT. tachycardia.

Transfuse, banding if varices are the cause, surgery. Chest drain.

7 Tension Blue, collapsed, absent CXR (if there is pneumothorax breath sounds on one time). side. Trachea deviated to opposite side. 8 Diabetic ketoacidosis Hyperventilating, dry, history of thirst and polyuria, abdo pain. Neurology with level (Section 2.7.2.6). Headache, tender temporals, visual disturbance. Gases, blood glucose, urinalysis (shows ketones). MRI cord. ESR.

Insulin, fluids, potassium.

9 Spinal cord compression 10 Temporal arteritis

Surgery if needs be. Steroids.

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126 Chapter 4

4.2. THE TEN MOST COMMON PRESENTING COMPLAINTS

This section could be a textbook in itself, but here goes, diagnostic medicine slashed to the bone. The problems are summarised in Table 4.2. Breathlessness is a very common symptom, and is usually due to lung or cardiac problems. Key diagnoses in these two systems are: exacerbation of COPD, pulmonary embolus, pneumothorax, pleural effusion, fibrotic lung disease, pulmonary oedema. Non-cardiopulmonary causes include very severe anaemia and metabolic acidosis. Headache is very common. The three big ones are raised intracranial pressure, meningitis and subarachnoid haemorrhage. Non-lethal but troublesome causes include migraine, trigeminal neuralgia, cluster headache and tension headache. Abdominal pain has a thousand causes. The intestine can ulcerate, block, inflame or perforate. The pancreas can become inflamed. Stones can block bile duct or ureters. Ovaries and uterus can cause grief too. The aorta can dilate up. Vomiting blood is simpler: gastric or duodenal ulceration, or varices. Chest pain is often caused by ischaemic heart disease, but the oesophagus, trachea, pleural and pericardial membranes can cause pain. The thoracic aorta can stretch or rip. Fatigue: the hardest. Can be endocrine, renal, rheumatological, neurological or haematological. Or cardiac. The unconscious patient: has to have something neurological. Raised intracranial pressure is very serious, but rare. Poisoning is a common cause. Fever: check the CRP (although it can be normal in the first day or two of serious infection). Check all the systems including the heart valves. Jaundice is typically caused by disease in the liver or by obstruction to the biliary system, but dont forget about haemolytic anaemia (which is pre-hepatic jaundice).

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Table 4.2. Ten Most Common Presenting Complaints. Main Differential CXR, gases, CTPA. Tension pneumothorax. Tests Dont Miss

Complaint

Breathlessness

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Headache

CT, LP, ESR.

Raised ICP, temporal arteritis. Perforation.

Abdominal pain

4 5

Vomiting blood Chest pain

CT abdo, amylase. WBC, CRP. Endoscope, PTT. CXR, ECG, CTPA.

Fatigue

Varices. Aneurysm. MI. Addisons. Hypoglycaemia.

Unconscious

Heart or lung problems. Asthma (wheeze); pulmonary oedema (crackles+++); PE (little to find, usually); pneumothorax (absent breath sounds on the affected side). Meningitis (fever, meningism), SAH (sudden onset, meningism), raised ICP, migraine, tension headache, temporal arteritis. Abdo sepsis, GI perforation, obstruction, ischaemia, pancreatitis, aneurysm, biliary and renal colics. Peptic ulcer, bleeding varices. Angina, pulmonary embolus, pleurisy, aneurysm. oesophagitis, pericarditis. Endocrine, renal, inflammatory, haematological, psychological. Drugs (opiates, benzos), raised ICP, stroke, SAH, hypoglycaemia. Arrhythmia, seizure, faint. Septic shock.

Collapsed and re-awoke Fever

Infection (any system!), lymphoma.

Four Lists of Ten 127

10

Jaundice

Haemolysis (high bilirubin, ALT, alk phos normal), hepatocellular liver disease (increased ALT), biliary obstruction (increased alk phos).

FBC, U&E, endocrine tests. CT head, blood sugar. 24-hr ECG, CT head, EEG. Cultures, FBC, CRP, many scans, echo. LFTs, FBC, US liver, CT liver.

Surgically remediable obstruction.

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4.3. THE TEN MOST USEFUL TESTS

This is a bit of a cheat because many of the tests here are multi-dimensional. For instance a blood count gives you 7 independent pieces of information (Hb, red cell count. MCV, platelet count, neutrophil, lymphocyte and eosinophil counts.) We are not including urinalysis here, considering it to be part of physical examination. We certainly cannot do without biopsies and histological examination but they are specialised tests based on many further investigations. I always like a good blood count. Sick patients are very often anaemic. The size of the red cells tells you about iron, thalassaemias, B12, folate and the patients alcohol intake. The white count (with differential) is a vital investigation in infection. Platelets tell you about bleeding. You cannot know about the kidneys (Section 2.5) without the U&E. Sodiums and potassiums are important for body fluids and for the stability of excitable cells. The liver tests are crucial to sorting out the jaundiced patient. The albumin drops when hepatic synthetic function is poor, or in inflammation, or if proteins are being lost through leaky nephrotic glomeruli. The CRP is a tremendously useful measure of inflammation in all its forms; the chest X-ray is a vital step in the diagnosis of breathlessness; the ECG is vital for sorting out cardiac rhythm disturbances, for diagnosing cardiac ischaemia in all its forms, and pericarditis; the CT head is extremely useful for the assessment of an unconscious patient; the ultrasound of the abdo can show you stones, tumours, collections of pus. It could be argued that a CT would be even better here. Bacterial culture is absolutely invaluable if you can get it. Lastly, lumbar puncture is key to the diagnosis of meningitis, subarachnoid haemorrhage, multiple sclerosis, viral infections, and idiopathic raised intracranial pressure.

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Four Lists of Ten 129 Table 4.3. The Ten Most Useful Tests in Medicine. Test 1 2 FBC U&E What it Tells You Whether patient is anaemic or not. Size of the red cells (alcohol, iron, B12, folate). White count (infection); platelet count (bleeding). How the kidneys are working (no other way of knowing this). Sodium and potassium status, relevant to hydration and function of excitable tissues. What the liver is like. The albumin level reflects not only liver function but also infection, inflammation, renal protein loss and malnutrition. Inflammation in all its forms: autoimmune, infective, other. Huge dynamic range, from 0500. Extremely useful broad-spectrum test for diagnosis and for monitoring progress. Lung parenchyma (oedema, infection, fibrosis, tumour). Pleura (effusion, tumour). Heart size and contour. Pneumothorax. Ribs. Clavicles. Mediastinum: nodes, tumour. Cardiac rhythm. ST segments and T waves (ischaemia, pericarditis). Myocarditis. Left and right-sided hypertrophies. Space occupying lesion(s); bleeds; skull fracture; size of ventricles; displacement of midline; oedema in tumour and stroke. Collections of pus; biliary or renal obstruction; biliary or renal stones; tumours. Bacteriological diagnosis, from pus, sputum, blood, CSF, urine, ascitic, pleural or even pericardial fluid. Identity of bug and antibiotic sensitivity: crucial data. Pressure; biochemistry; protein; glucose; presence or absence of blood; oligoclonal bands in MS; cells: neutrophils, lymphocytes, other e.g. tumour; bacteriology: Gram postive or negative bacteria, TB, fungi; culture: bacteria; PCR: viruses.

LFTs

CRP

CXR

6 7 8 9

ECG CT head US abdo Bacterial culture Lumbar puncture

10

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130 Chapter 4

4.4. THE TEN MOST USEFUL DRUGS

The pharmaceutical armoury is now a very big one. The World Health Organization List of Essential Medicines runs to 37 pages and about 330 drugs, but I think that if I was allowed only ten these are the ones I would want at UCH. See Table 4.4. To make this reasonable I am confining myself to drugs that can be prescribed by the docs on a general ward. I am excluding specialist treatments such as chemotherapy for cancer, immunosuppression after transplant, sophisticated AIDS treatment, anaesthetics, topical antiseptics, IV fluids, oxygen, blood transfusion. Apart from insulin I am avoiding endocrine replacement. In addition to prescribed drugs you must have IV saline, but its not on this list because it is not a drug. Half of the patients in the hospital get it, for fluid replacement after vomiting, diarrhoea, excessive diuretics, haemorrhage, in sepsis: it goes on and on.

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Four Lists of Ten 131 Table 4.4. The Ten Most Useful Drugs in Medicine. Class 1 2 3 4 Antibiotic Anticoagulant Diuretic Analgesic Drug Amoxicillin + clavulanic acid Heparin Furosemide Morphine Utility Best all-round antibiotic. Treatment and prophylaxis of thrombotic conditions. Cardiac failure, hypertension, oedematous states. Addictive, but a highly effective analgesic. Very useful in pulmonary oedema. Causes vomiting. Suppression of pathological inflammation. Specific to one disease, but diabetes is a very common one. Asthma is also very common. Control of delirium, hallucination, psychosis. Control of seizures. Useful antiarrhythmic (supraventricular and ventricular tachycardias, atrial fibrillation) in spite of its thyroid and lung side effects (which are associated with long-term use).

5 6 7 8 9 10

Steroid Diabetic Bronchodilator Anti-psychotic Anti-convulsant Anti-arrhythmic

Prednisolone Insulin Salbutamol Haloperidol Lorazepam Amiodarone

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