The Foundation Years最新文献

Dizziness and syncope are common symptoms in the general population, especially the elderly. Syncope can be disabling and result in physical injury and loss of independance. Causes can be divided into arrhythmia, mechanical reduction in cardiac output, inappropriate vasodilatation, neurogenic and metabolic. Patients with cardiac syncope have a poor prognosis unless the cause is quickly identified and treated. The key to making a diagnosis is obtaining a clear history from the patient or a witness of the temporal pattern of symptoms including precipitants, a description of the blackout itself, and speed of recovery. Examination focuses on identification of signs of structural heart disease and postural hypotension. If the history suggests a cardiac diagnosis, echocardiography and ambulatory ECG recording are helpful investigations. For patients with intermittent symptoms suggesting arrhythmia, implantable ECG loop recorders are increasingly used. Tilt testing is used to investigate possible vasovagal syncope, and EEG or MRI head scan can be used to identify potential neurologocal causes of blackouts.

Cardiovascular causes of syncope are treated by removal of reversible triggers (e.g. drugs that cause bradycardia or hypotension) or by treatment of the underlying condition (e.g. permanent pacemaker for symptomatic bradycardia, aortic valve surgery for aortic stenosis). Vasovagal syncope is more difficult to treat but can be helped by avoiding identifiable triggers, use of medication and in some cases dual chamber pacing.

Alcohol withdrawal syndrome is a common medical problem and occurs within hours of alcohol cessation or reduction. It is characterized by autonomic hyperactivity, tremor, anxiety, restlessness seizures, hallucinations and delirium. The alcohol withdrawal syndrome may develop in patients admitted to hospital for an unrelated illness (e.g. for an operation) or patients may present in a confused state to the Emergency Department, due to the onset of the syndrome. In both these circumstances, which are medical emergencies, the diagnosis is often delayed as it is not considered. When considered, treatment is often less than optimal. The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale should be used to determine both the severity of withdrawal and the need for treatment. If drug treatment is required, patients should be treated with regimens which are patient-specific and flexible to respond to changes in severity of withdrawal (symptom-triggered). Fixed treatment schedules, where the patient is given a standard regimen irrespective of their symptoms, are inappropriate. Long-acting benzodiazepines such as diazepam are the agents to first choice as they have better documented efficacy, a greater margin of safety and a lower abuse potential. Diazepam may be given orally or intravenously, though the oral route is preferred if the patient is able to comply. All patients should receive thiamine 100 mg b.d. orally, unless Wernicke’s encephalopathy or Korsakoff’s psychosis is suspected, when parenteral administration of B vitamins is appropriate.

The newly qualified doctor is often at the frontline of acute medical services and is therefore likely to be called to situations where a patient is aggressive. This article discusses the systematic assessment of such situations, including an assessment of aetiology and risk assessment. Management issues are outlined with reference to available strategies. Relevent foundation competences are highlighted.