The Foundation Years最新文献

The foundation doctor may need to deal with pituitary or adrenal pathology in the acute setting as part of a medical emergency or because an incidental lesion within the gland has been found on imaging. Pituitary apoplexy refers to a vascular event within a pituitary tumour, and the clinical features include acute onset headache, reduced consciousness, visual disturbance and diplopia. A high index of suspicion is required to make the diagnosis and appropriate imaging is needed. Acute adrenal insufficiency presents with hypoglycaemia, hypotension, hyponatraemia, hyperkalaemia and dehydration. Intravenous hydrocortisone should be given empirically if the clinical features are suggestive, as the condition may be fatal if untreated. A systematic approach is required to determine the clinical significance of incidentally found pituitary and adrenal lesions, which includes determining the size of the lesion and biochemical assessment to exclude endocrine hypersecretion.

Diabetic emergencies are a fairly common occurrence in acute medical care. In particular, diabetic keto-acidosis (DKA) and hyper-osmolar non-ketotic states are potentially fatal conditions. A patient may present in a grossly obtunded state with profound metabolic derangement. In DKA, arterial blood gas (ABG) analysis may reveal a pH of less than 7.0. This degree of acidosis is generally non-survivable with any other cause, however with DKA, prompt appropriate treatment and close monitoring usually results in a rapid and full recovery. The importance of good glycaemic control in the context of acute myocardial ischaemia and general critical illness is also discussed.

Diabetes mellitus (DM) is a common medical condition, which is estimated to affect approximately 4% of the adult population and is present in 10–20% of all UK hospital inpatients. Expenditure on DM accounts for approximately 10% of the UK health budget.

DM is characterized by both microvascular and macrovascular complications. Microvascular complications affecting the eye (retinopathy), the kidneys (nephropathy) and feet (neuropathy) are unique to the diabetic condition. However, macrovascular complications, including an increased risk of coronary heart disease, cerebral vascular disease and peripheral vascular disease, account for 75% of mortality, and occur at a much younger age compared to the non-diabetic population.

Early assessment, diagnosis and management of patients are essential for reducing the incidence of diabetes and also minimizing the complications. In recent years there has been a huge increase in therapeutic options.

Thyroid emergencies are rare but are important to recognise because of the high mortality associated with them. Thyroid storm is a clinical syndrome associated with fever, central nervous effects, gastrointestinal-hepatic dysfunction, tachycardia and congestive cardiac failure. Myxoedema coma is typically associated with hypothermia, hypoventilation, hyponatraemia, hypoglycaemia and decreased mental function. Surgical and anaesthetic aspects of thyroid disease include the assessment of patients with thyroid dysfunction before non-thyroidal surgery, recognising post-thyroidectomy complications, and the management of acute upper airway obstruction due to goitre. Factors including systemic illness, medication and pregnancy may affect thyroid function, and it is important to consider these before deciding on the appropriate management strategy.

Diabetes mellitus (DM) is a very common condition in the general population. It is even more common in the surgical inpatient population, due to its many complications leading to an increased need for surgery, particularly vascular, renal and ophthalmic procedures. A foundation doctor may be expected to assess such patients and prepare them for anaesthesia and surgery. What sort of management plan might be required for an obese elderly type 2 diabetic (T2DM) requiring a total knee replacement, or a young type 1 diabetic (T1DM) requiring a laparotomy for inflammatory bowel disease?