The Foundation Years最新文献

Management of the multiply injured patient requires a co-ordinated multi-disciplinary approach in order to optimise patient outcomes. With most acute hospitals receiving at least one multiple trauma case per week it is highly likely that a foundation doctor will be involved in the care of these patients, either in the acute resuscitation phase or following surgery. A working knowledge of the sort of problems these patients encounter is therefore vital to ensure that life-threatening injuries are recognised and treated in a timely fashion and that more minor associated injuries are not forgotten. This article outlines the management of polytrauma patients using the Advanced Trauma Life Support (ATLS) principles and highlights the areas of specific involvement from the musculoskeletal team.

Musculoskeletal (MSK) plain film radiography remains an integral part of MSK imaging especially in emergency medicine and its interpretation is an important skill to learn. Other imaging modalities are being utilised increasingly to complement plain films in the investigation of musculoskeletal pathology.

In this article musculoskeletal disease is discussed under the headings of trauma, infection, neoplastic disease, arthritis and metabolic bone disease. The various imaging modalities including their strengths and weaknesses are discussed. Emphasis is placed on the imaging modalities most appropriate in specific clinical settings and key radiological findings are described and examples included.

Infection in bone and joints is a potentially very serious condition. Prompt recognition, appropriate referral and expeditious treatment are essential in order to avoid serious long term sequelae. Acute septic arthritis is an orthopaedic emergency which requires removal of the pus from the joint and intravenous antibiotics. Acute osteomyelitis, if diagnosed early, will usually settle with a course of antibiotics alone (these should be started immediately after obtaining blood cultures). If the diagnosis is delayed, the patient will require surgical drainage. Chronic osteomyelitis is a variable condition unless. If it is causing minimal morbidity it can be treated non-operatively, more commonly, however, it requires surgical treatment to drain the pus and remove the areas of dead bone. In some cases of implant related sepsis, it is possible to retain the prosthesis but in the majority, the implant has to be revised. In general, in patients with orthopaedic infections, wherever possible, it is preferable to obtain a microbiological diagnosis before initiating antibiotic therapy as appropriately targeted antibiotic therapy increases the chances of eradication of infection.

The limping child is a common reason for attendances to the emergency department. It is very likely that the Foundation Years doctor will have to assess and treat these patients. While the large majority of the patients have typically benign diagnoses, there are very important causes of a limp in a child that must be excluded.

These include malignancy and acute sepsis of the hip. It is important to determine the salient features on history and examination and to conduct the appropriate investigations.

This article outlines how children with a limp may present clinically and details the acute assessment that must be carried out to exclude the rare but potentially devastating causes of a limp. The details of diagnosing the more common conditions causing a limp in a child are also described.

Imaging has become increasingly important in the diagnosis of patients presenting with abdominal symptoms, a very common scenario in clinical practice. The introduction of new imaging techniques has altered the way many bowel pathologies are now investigated.This article concentrates on the role of imaging in the assessment of patients who present with symptoms or signs related to the upper and lower gastrointestinal (GI) tract, excluding the hepatobiliary system and pancreatic disease (these will be covered elsewhere). Imaging strategies are presented in relation to common or important clinical presentations, with discussion of the relative strengths and weaknesses of individual modalities. This article will also include newer applications such as computed tomography (CT) colonography, CT angiographic techniques, magnetic resonance imaging (MRI) and endoluminal ultrasound.

Background

non-cardiac chest pain (NCCP) is recurrent retrosternal chest pain in the absence of significant coronary artery disease. It can affect up to 25% of the population.

Pathophysiology

good history and examination help to differentiate between causes of chest pain, such as coronary heart disease, musculoskeletal pain, abdominal disease, pulmonary causes and oesophageal pathology. Targeted investigations should be performed according to clinical suspicion.

Patients with a high risk of ischaemic heart disease should have cardiac investigations. Those likely to have NCCP should, if possible, be identified early, to prevent the all-too-common scenario of patients continuing for years to present to primary and secondary healthcare professionals and remaining limited in their ability to perform physical activities or to work. Gastro-oesophageal reflux disease is a common cause of NCCP, occurring in up to 50% of patients. If there are any red flag signs, a gastroscopy should be performed to rule out upper gastro-intestinal pathology. Oesophageal dysmotility, including achalasia and diffuse oesophageal spasm, are rare causes, while visceral hypersensitivity is common. A proportion of patients have psychiatric disease in isolation or combination with the above.

Management

in primary care, an empirical trial of a four-week course of twice-daily proton pump inhibitor (PPI) is a useful diagnostic and therapeutic test. In case of response, maintenance dose PPI should be continued. Referral to a gastroenterologist should be considered if there is no response. 24-hour oesophageal pH monitoring can identify patients with reflux unresponsive to PPI; oesophageal dysmotility can be identified by manometry in selected patients. Tricyclic antidepressants at relatively low dose may have a role. Behavioural therapy and hypnotherapy have been found to be useful in selected cases.

Summary

chest pain should be taken seriously, with any underlying pathology identified and treated early. Patients with NCCP should receive repeated and consistent reassurance, in the hope of averting chronic disability. A multidisciplinary approach to NCCP may be required in those with chronic symptoms.