The RCP Medicine podcast is a weekly discussion of different topics relevant to physicians and physician associates.
The podcast is hosted by Dr Amie Burbridge, a consultant in acute medicine from Coventry, and Dr Hussain Basheer, RCP Education fellow and a respiratory registrar from Kent, Surrey and Sussex.
Each week they discuss and explore a different topic including:
- real-life clinical cases
- new evidence-based guidelines
- specific physician issues in the modern healthcare environment.
The views expressed in this podcast are those of Amie and Hussain and not necessarily the RCP.
Amie and Hussain are back with another medical emergency. This week it’s diabetic ketoacidosis. Investigations and management are discussed. Amie explains why hyperchloraemic acidosis develops and covers the all-important pathophysiology of DKA.
- Joint British Diabetes Society. Inpatient Care Group. The management of diabetic ketoacidosis in adults, 2nd edn. London: Diabetes UK, 2013. Available from https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf.
- NICE. Type 1 diabetes in adults: diagnosis and management Clinical guideline [NG17]. London: National Institute for Health and Care Excellence, 2015 [Updated July 2016]. Available from https://www.nice.org.uk/guidance/ng17.
Amie and Akon approach a difficult case of jaundice. How to manage decompensated liver disease and the latest guidelines are discussed. Amie covers the physiology of the liver, and the huge impact of poor communication is realised.
Amie and Hussain discuss a case with a very unexpected cause. Amie revisits the Kreb's cycle and Hussain remains baffled.
- NICE. Alcohol-use disorders: diagnosis and management of physical complications [CG100]. London: National Institute for Health and Care Excellence, 2017. Available from https://www.nice.org.uk/Guidance/CG100
Amie and Hussain are back this week to discuss a missed case of acute kidney injury. The RCP Acute care toolkit on AKI is reviewed as well as the NICE guidelines.
- Royal College of Physicians. Acute care toolkit 12: acute kidney injury and intravenous fluid therapy. London: RCP, 2015. Available from https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-12-acute-kidney-injury-and-intravenous-fluid-therapy
- UK Renal Registry & NHS England. Think kidneys: communities at risk of developing acute kidney injury. NHS England, 2018. Available from https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2018/11/Nov-18-Communities-at-risk.pdf
- NICE. Point of care creatinine tests to assess kidney function before administering intravenous contrast for computed tomography (CT) imaging: final scope. London: National Institute for Health and Care Excellence, 2018. Available from https://www.nice.org.uk/guidance/indevelopment/gid-dg10024/documents
- NICE. Acute kidney injury: prevention, detection and management [CG169]. London: National Institute for Health and Care Excellence, 2013. Available from https://www.nice.org.uk/guidance/cg169
Amie and Dr Becky Chubb take us through the case of an 82 year old who has a surprising diagnosis.
20. Another crisis
Dr Akon Esara, education fellow, takes us through the key points of a frequent attender.
- NICE. Sickle cell disease: managing acute painful episodes in hospital: Clinical guideline [CG143]. London: National Institute for Health and Care Excellence, 2012. Available from https://www.nice.org.uk/guidance/cg143.
Hussain and Amie discuss their general medical approach to Upper GI bleed management, with a little help from a couple of famous names.
- Siau K, Chapman W, Sharma N et al. Management of acute upper gastrointestinal bleeding: an update for the general physician. Journal of Royal College of Physicians of Edinburgh 2017; 47(3):218-30. Open access at https://www.rcpe.ac.uk/sites/default/files/jrcpe_47_3_bhala.pdf.
- Rockall T. 1998, Acute upper gastrointestinal haemorrhage: epidemiology, risk factor assessment and national audit of management, MD thesis, University of London.
- Rockall T, Logan R, Devlin H et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38(3):316–21. Open access at https://gut.bmj.com/content/38/3/316.short.
- Blatchford O, Murray W, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. Lancet 2000; 356(9238):1318–21. Full text for RCP members via Athens account.
- NICE. Acute upper gastrointestinal bleeding in over 16s: management: Clinical guideline [CG141]. London: National Institute for Health and Care Excellence, 2012 [Updated 2016]. Available from https://www.nice.org.uk/guidance/cg141.
- Villanueva C, Colomo A, Bosch A et al. Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine 2013; 368(24):11–21. Open access at https://www.nejm.org/doi/full/10.1056/NEJMoa1211801.
- Gralnek I, Dumonceau J, Kuipers E et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47(10):1–46. Open access at https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0034-1393172.
In her second guest episode, consultant psychiatrist Dr Becky Chubb goes through the key points of delirium diagnosis and management.
- NICE. Delirium: prevention, diagnosis and management [CG103]. London: National Institute for Health and Care Excellence, 2010. Available from https://www.nice.org.uk/guidance/cg103.
Hussain and Amie delve into an unusual case where a very commonly prescribed drug becomes the focus.
- Arlt W et al. Society for Endocrinology endocrine emergency guidance: emergency management of acute adrenal insufficiency.Endocrine Connections 2016; 5(5):G1-G3. Open access at https://ec.bioscientifica.com/view/journals/ec/5/5/G1.xml.
- Joseph RM, Hunter AL, Ray DW et al. Systemic glucocorticoid therapy and adrenal insufficiency in adults: a systematic review. Seminars in Arthritis and Rheumatism2016; 46(1):133-141. Open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4987145/.
- Charmandari E, Nicolaides NC and Chrousos GP. Adrenal insufficiency. Lancet 2014; 383:2152-67. Full text for RCP members via Athens account.
Amie and Hussain unpick a case with this most common of symptoms, presenting to an ambulatory care unit.
- Berbari EF, Kanj SS, Kowalski TJ et al. Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clinical Infectious Diseases 2015; 61(6): e26–e46. [Open access at https://academic.oup.com/cid/article/61/6/e26/452579].
Amie and guest consultant psychiatrist Dr Becky Chubb take us through the key points of mental health in medicine, including the all-important mental state examination.
- Naylor C, Das P, Ross S et al. Bringing together physical and mental health: a new frontier for integrated care. London: King’s Fund, 2016. https://www.kingsfund.org.uk/publications/physical-and-mental-health.
14. Night fever
Amie and Hussain de-brief about a case presenting with fever, weight loss and night sweats. All is not as it seems.
- Sayarlioglu M. Remitting Seronegative Symmetrical Synovitis With Pitting Edema (RS3PE) Syndrome and Malignancy. European Journal of General Medicine 2004; 1(2):3-5.
- Dejaco C, Singh YP, Perel P, et al. 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol. 2015;67:2569-2580.
- Dasgupta B, Borg FA, Hassan N, et al on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guidelines for the management of polymyalgia rheumatic. Rheumatology 2010 Volume 48:1: 186–190: https://doi.org/10.1093/rheumatology/kep303a.
Hussain and Amie compare their generalist approaches to the ‘low sodium’ result.
- Spasovski G, Vanholder R, Allolio D et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. European Journal of Endocrinology 2014; 170(3):G1–47. [Open access at: https://eje.bioscientifica.com/view/journals/eje/170/3/G1.xml ]
- Grant P, Ayuk J, Bouloux PM et al. The diagnosis and management of inpatient hyponatraemia and SIADH. European Journal of Clinical Investment 2015; 45(8):888–894. [Open access at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744950/].
Hussain recalls the drainage of a hepatic hydrothorax, and a rare complication.
- Echevarria C, Twomey D, Dunning J et al. Does re-expansion pulmonary oedema exist? Interactive CardioVascular and Thoracic Surgery 2008; 7(3):485-489. [Open access at https://academic.oup.com/icvts/article/7/3/485/673351].
- Kasmani R, Irani F, Okoli K et al. Re-expansion pulmonary edema following thoracentesis. CMAJ 2010; 182(18):2000–2002. [Open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001507/].
- du Plessis M, Ramai D, Shah S et al. The clinical anatomy of the musculotendinous part of the diaphragm. Surgical and Radiologic Anatomy 2015; 37(9):1013-1020. [Full text for RCP members via Athens account].
- Singh A, Bajwa A and Shujaat A. Evidence-based review of the management of hepatic hydrothorax. Respiration 2013; 86(2):155-173. [Open access at https://www.karger.com/Article/FullText/346996].
- Breu T. Why are right sided pleural effusions more common in patients with cirrhosis? 19 January 2019. [Twitter] Available at: https://twitter.com/tony_breu/status/1086725305937653760?lang=en.
This week Amie explores the investigation and management of hypercalcaemia.
- Turner JJO. Hypercalcaemia – presentation and management. Clinical Medicine 2017; 17(3):270-273. [Open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297576/].
- Walsh J, Gittoes N, Selby P [Society for Endocrinology Clinical Committee]. Society for Endocrinology endocrine emergency guidance: Emergency management of acute hypercalcaemia in adult patients. Endocrine Connections 2016; 5(5):G9–G11. [Open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5314807/].
Amie gives her take on the guidelines of pneumonia management, sometimes complicated by influenza.
- NICE. Pneumonia in adults: diagnosis and management: Clinical guideline [CG191]. London: National Institute for Health and Care Excellence, 2014. Available from https://www.nice.org.uk/guidance/cg191.
- Lim WS, Smith DL, Wise MP et al. British Thoracic Society community acquired pneumonia guideline and the NICE pneumonia guideline: how they fit together BMJ Open Respiratory Research 2015; 2(1):e000091. [Open access at https://bmjopenrespres.bmj.com/content/2/1/e000091].
- Lim WS, van der Eerden MM, Laing R et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58(5):377-382. [Open access at https://thorax.bmj.com/content/58/5/377].
- Jefferson T, Jones MA, Doshi P et al. Neuraminidase inhibitors for preventing and treating influenza in adults and children. Cochrane Database of Systematic Reviews 2014; Issue 4. Art. No.: CD008965. [Open access at https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008965.pub4/abstract].
- Grudzinska FS, Dosanjh DP, Parekh D et al. Statin therapy in patients with community-acquired pneumonia. Clinical Medicine 2017; 17(5):403-407. [Open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301923/].
- Muthuri SG, Venkatesan S, Myles PR et al. Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: a meta-analysis of individual participant data. Lancet Respiratory Medicine 2014; 2(5):395-404. [Open access at https://www.ncbi.nlm.nih.gov/pubmed/24815805].
Hussain recalls a case presenting to the acute medical take with a unilateral pleural effusion, highlighting key initial investigations and management.
- British Thoracic Society. Pleural Disease Guideline Group. BTS pleural disease guideline 2010. Thorax 2010; 65(Suppl 2). [Open access at https://thorax.bmj.com/content/65/Suppl_2].
Amie recollects a serious case which highlights the importance of prompt recognition and treatment of meningitis.
- van de Beek D, de Gans J, Spanjaard L et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351:1849-1859. [Open access at https://www.nejm.org/doi/full/10.1056/NEJMoa040845].
- McGill F, Heyderman RS, Michael BD et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. Journal of Infection 2016; 72(4):405-438. [Open access at https://www.journalofinfection.com/article/S0163-4453(16)00024-4/fulltext].
Amie investigates the evidence-base behind lumbar punctures and headaches.
- Carpenter CR, Hussain AM, Ward, MJ et al. Spontaneous subarachnoid hemorrhage: a systematic review and meta-analysis describing the diagnostic accuracy of history, physical examination, imaging, and lumbar puncture with an exploration of test thresholds. Academic Emergency Medicine 2016; 23(9):963-1003 [Open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5018921/].
- Perry JJ, Sivilotti MLA, Sutherland J et al. Validation of the Ottawa subarachnoid haemorrhage rule in patients with acute headache. Canadian Medical Association Journal 2017; 189(45):e1379-e1385. [Open access at http://www.cmaj.ca/content/190/6/E173].
- Royal College of Physicians. National clinical guideline for stroke, 5th ed. London: Royal College of Physicians, 2016. Available from https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines
Valle AJ, Fonseca Del Pozo FJ, Vaquero Alvarez M et al. Sudden headache, lumbar puncture, and the diagnosis of subarachnoid hemorrhage in patients with a normal computed tomography scans. Emergencias 2018; 30(1):50-53. [English abstract available at https://www.ncbi.nlm.nih.gov/pubmed/29437311].
Amie talks us through a hard-hitting case of infective endocarditis.
- Habib G, Lancellotti P, Antunes MJ et al. 2015 ESC Guidelines for the management of infective endocarditis. European Heart Journal 2015; 36(44):3075-3128. [Full text for RCP members via Athens account]
- Darjee R and Gibb AP. Serological investigation into the association between streptococcus bovis and colonic cancer. Journal of Clinical Pathology 1993; 46(12):1116-1119. [Full text for RCP members via Athens account].
- Li JS, Sexton DJ, Mick N et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clinical Infectious Diseases 2000; 30(4):633-638. [Full text for RCP member via Athens account].
Hussain discusses a tragic case that highlights the challenges of having difficult conversations during a busy on-call shift.
- Baile W, Buckman R, Lenzi R et al. SPIKES – A six-step protocol for delivering bad news: application to the patient with cancer. The Oncologist 2000; 5(4):302-311. [Full text for RCP members via Athens account].
Hussain runs through the management of COPD presentations on the acute take, with some important points about smoking and vaping.
- Stone RA, McMillan V, Mortier K et al. COPD: Working together. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Clinical audit of COPD exacerbations admitted to acute hospitals in England and Wales 2017. National clinical audit report. London: RCP, April 2018. https://www.rcplondon.ac.uk/projects/outputs/copd-working-together-clinical-audit-2017
- Steer J, Gibson J and Bourke SC. The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax 2012; 67(11):970–976. [Full text for RCP members via Athens account].
Amie gives us a quick run-through of the investigation and management of the acute, hot joint.
- Coakley G, Mathews C, Field M et al. [on behalf of the British Society for Rheumatology Standards, Guidelines and Audit Working Group] BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology 2006; 45(8):1039–1041. [Full text for RCP members via Athens account].
- Farrow L. A systematic review and meta-analysis regarding the use of corticosteroids in septic arthritis. BMC Musculoskeletal Disorders 2015; 16:241.
Hussain recounts a devastating neurology case from a weekend on-call.
- Al-Hourani K, Al-Aref R and Mesfin A. Upper cervical epidural abscess in clinical practice: diagnosis and management. Global Spine Journal 2016; 6(4):383-393. [Full text for RCP members via Athens account].
- Chao D and Nanda A. Spinal epidural abscess: a diagnostic challenge. American Family Physician 2002; 65(7):1341-1346.
Amie explores the investigation and management of suspected pulmonary emboli on the acute take, discussing the merits of ambulatory care, with references to recent NICE and BTS guidelines.