Acute medicine
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Sepsis commonly presents to the acute medicine unit (AMU). Timely recognition and treatment can reduce the significant associated mortality, but United Kingdom AMUs and emergency departments are often inadequately equipped to manage sepsis with early-goal directed therapy. ⋯ Demographic, physiological and microbiological data, and information about the provision and timing of care were collected in real time. Treatment fell below "surviving sepsis" targets with only 28% of patients receiving sufficient fluid, and 64% receiving antibiotics within 3 hours, associated with delays in seeing physicians; however despite this mortality was lower than the nationally quoted average (14% at 90 days).
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This study assessed the role of frailty assessment in the AMU. ⋯ Moderate-severe frailty in people aged 70+ was common and was predictive of higher mortality, but did not appear to predict admission, length of stay or readmission.
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Comparative Study
Performance of TOTAL, in medical patients attending a resource-poor hospital in sub-Saharan Africa and a small Irish rural hospital.
Recently a very simple, easy to remember early warning score (EWS) dubbed TOTAL has been reported. The score was derived from 309 acutely ill medical patients admitted to a Malawian hospital and awards one point for Tachypnea >30 breaths per minute, one point for Oxygen saturation <90%, two points for a Temperature <35°C, one point for Altered mental status, and one point for Loss of independence as indicated by the inability to stand or walk without help. TOTAL has an area under the receiver operator characteristic curve (AUROC) for death within 72 hours of 78%. ⋯ The discrimination of TOTAL is exactly the same in elderly Irish patients as it is in young African patients. The score is easy to remember, easy to calculate, and works over a broad range of patients.
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Chest pain is a common symptom amongst patients presenting to the acute medical unit, and presents a diagnostic challenge. We present the case of a previously healthy 65 year old year old gentleman with chest pain and subsequent vomiting, treated initially as an acute coronary syndrome, despite normal ECG and troponin. ⋯ This revealed evidence of oesophageal rupture (Boerhaave's syndrome). Despite early surgical intervention our patient suffered a number of complications and continues his recovery in hospital three months post presentation.