The Foundation Years最新文献

Glomerular disease has a variety of presentations that may be commonly encountered in clinical practice. The list of potential causes is extensive, but by focusing on the clinical presentation a swifter diagnosis may be reached. This article focuses on how basic investigations are used in everyday practice to inform an eventual diagnosis. Often, therapies for glomerular dysfunction are not disease-specific but rather directed against recognized risk factors for progression of chronic kidney disease. These are discussed, and safeguards for treating individuals with glomerular disease are described.

The patient with acute leg weakness is a medical emergency. A logical and safe clinical approach first requires a basic understanding of the relevant neuro-anatomy, (so don’t skip the following section!). The doctor must obtain a detailed history and perform a competent examination. The clinical case must then be discussed promptly with senior staff, and investigations and management planned thereafter. Rather than providing a detailed account of certain specific diseases, for example Guillain-Barré Syndrome, this article focuses on the diagnostic assessment of patients with acute leg weakness.

Coma and impaired consciousness are frequent medical emergencies. Assessment of such patients requires a working knowledge of the neuro-anatomical basis of consciousness. Consciousness is dependent upon the integrity of two structures: the reticular activating system in the brainstem, which governs the level of arousal, and the cerebral cortex of both hemispheres, which determines the content of consciousness. Coma can result either from pathological processes in the brainstem or from diffuse pathology in the cerebral cortex. The Glasgow Coma Score (GCS) is invaluable for documenting the level of coma and monitoring for clinical change, but is of no diagnostic significance. A thorough neurological assessment should allow separation of patients into three separate groups: high likelihood of structural supra- or infratentorial pathology requiring urgent CT brain scans (e.g. cerebrovascular disease); coma with meningeal irritation where lumbar puncture and prompt antibiotic therapy may be life-saving (e.g. bacterial meningitis); and patients with no focal signs or meningeal irritation where metabolic and toxic causes are common (e.g. drug overdose, hypoglycaemia, hyponatraemia and liver failure). The prognosis of coma depends on aetiology, depth and duration of coma and presence of brainstem reflexes.

Seizures may be a manifestation of epilepsy, but may also have other causes, including toxic or metabolic disturbances, or an acute insult to the brain, such as head injury or encephalitis. Most seizures are self-limiting, and will have ceased before the patient arrives at hospital. Where they are ongoing, the priority is resuscitation of the patient and appropriate treatment to terminate the seizure. In those in whom the episode has ceased, an eyewitness description of the event is crucial for confirmation of diagnosis. Investigations should be directed at excluding other possible causes of loss of consciousness (such as cardiac arrhythmias, where there is an appropriate history) and confirming the cause of the seizures. All patients with a new diagnosis of epilepsy should be referred to a specialist for further assessment and consideration of treatment. Patients and carers should be counselled about the implications of seizures and first aid management.

Headache is the most common presenting symptom in a neurological clinic. Although seldom life-threatening, it is a major cause of suffering, and loss of productivity at work due to headache is extremely costly.

Patients seeking advice about one particular headache often have a febrile illness such as influenza or sinusitis. Nevertheless, subarachnoid haemorrhage and meningitis must be considered in every patient.

Clinical assessment of a headache patient is almost wholly dependent on an adequate history. Specific structural causes such as temporal arteritis, cerebrovascular disease, sinusitis, trigeminal neuralgia, typical facial pain, subarachnoid haemorrhage and meningitis need to be considered first. Cervical spondylosis is the commonest cause of new headache in older people. Headache as a presenting symptom of disorders causing raised intracranial pressure is unusual, as most such patients have epilepsy or physical abnormalities reflecting the site of the lesion within the brain, but patients with a short history of headache should be investigated, even in the absence of physical signs. A minority of patients have cluster headache, which all competent physicians should be able to recognise.

Tension-type headache is extremely common, though seldom as incapacitating as migraine. Physicians should ensure that the patients are not abusing opioid or other analgesics, or taking oestrogenic hormones Most of these patients respond to tricyclic antidepressants and anti-inflammatory drugs. Migraine is the commonest cause of disabling recurrent headache; in population surveys only a minority of patients have headaches preceded by a visual, sensory or other aura disturbance. Triptan analgesics should be considered for all patients unresponsive to less expensive remedies. If the attacks occur twice or more monthly, patients should be considered for prophylactic treatment, with, for example, beta blockers, pizotifen, valproate or methysergide.

With careful diagnosis and appropriate treatment, most patients with disabling headaches can be helped a great deal.