Hot topics in Acute Medicine Dr Ben Mearns FRCP Consultant Physician in Acute & Elderly Medicine Chief of Medicine Surrey & Sussex Healthcare NHS Trust @BenMearns ben.mearns@sash.nhs.uk
Mr A - History Cough for 1 week Chest pain pleuritic nature Feeling hot and cold Short of breath
Mr A - Examination Cough for 1 week Temp 38.5 RR 24 Chest pain pleuritic nature BP 110/50 Feeling hot and cold P 110 regular Sats 93% on air Short of breath Chest Crackles right base PN Dull Resonance increased
Mr A - Examination Cough for 1 week Temp 38.5 RR 24 Chest pain pleuritic nature BP 110/50 Feeling hot and cold P 110 regular Sats 93% on air Short of breath Chest Crackles right base PN Dull Resonance increased NEWS = 7
Mr A Initial Treatment O2 Analgesia IV fluids Antibiotics
Mr A - Investigations WBC 17 Neut 11 CRP 220
Mr A - investigations Full blood count Urea and electrolytes Liver function tests Blood cultures CRP Lactate CXR CURB = 2
Mr A - Examination Cough for 1 week Temp 38.5 RR 24 Chest pain pleuritic nature BP 110/50 Feeling hot and cold P 110 regular Sats 93% on air Short of breath Chest Crackles right base PN Dull Resonance increased
Mr A - Reassessment Tired but feels better Temp 37.8 RR 20 Pain controlled BP 130/60 No longer feverish P 100 regular Sats 98% on 35% oxygen Breathing feels much better Chest Crackles right base PN Dull Resonance increased
Mr A what next? AMU Observations Review?
Mrs B - History Ca Breast 1 week post chemotherapy Unwell No specific symptoms
Mrs B - Examination Ca Breast Temp 39.0 RR 16 1 week post chemotherapy BP 120/80 Unwell P 90 regular Sats 97% on air No specific symptoms Examination Clear chest Soft non-tender abdomen Nil else to find
Mrs B - Examination Ca Breast Temp 39.0 RR 16 1 week post chemotherapy BP 120/80 Unwell P 90 regular Sats 97% on air No specific symptoms Examination Clear chest Soft non-tender abdomen Nil else to find NEWS = 1
Mrs B what next? Antibiotics
Mrs B Initial Treatment Antibiotics!! O2 if required Analgesia if required IV fluids if required
Mrs B - investigations Full blood count Urea and electrolytes Liver function tests Blood cultures CRP Lactate Other tests as directed by assessment
Mrs B diagnosis Diagnose neutropenic sepsis in patients having anticancer treatment whose neutrophil count is 0.5 10 9 per litre or lower and who have either: a temperature higher than 38 C or other signs or symptoms consistent with clinically significant sepsis.
Mrs B wants to go home
MASCC SCORE No/mild symptoms 5 SBP >90 mmhg 5 No COPD 4 Solid tumour or haematological with no prior fungal infection 4 No dehydration requiring IV fluids 3 Moderate symptoms 3 Outpatient status 3 Age <60 years 2 High risk less than 21
Ambulatory care http://www.ambulatoryemergencycare.org.uk/directory
Ambulatory care
Miss C - History Known depression Paracetamol OD Impulsive Needs to leave Refusing treatment
Miss C - History Known depression Temp 37.0 Paracetamol OD RR 20 BP 105/60 Impulsive P 100 regular Needs to leave Sats 98% on air Refusing treatment Examination Clear chest, slightly tender abdomen Seems distracted and distant Very low mood and matching affect
Miss C - investigations Full blood count Urea and electrolytes Liver function tests Clotting Venous ph & Bicarbonate 4hr Paracetamol level over the line ECG
Miss C initial treatment? Acetylcysteine
Miss C wants to go home
Capacity Principles of MCA Assume capacity All practicable steps to assist patient to decide Unwise decisions must be accepted An act done on a patient without capacity must be done in their best interests Least restrictive care Understand Retain Use to decide Communicate
Capacity When to check for capacity? Whenever a patient needs to make a decision about their care Specific to each decision Can change It is a constant and dynamic part of medical practice Understand Retain Use to decide Communicate
Best interests MCA (Section 4) Will capacity return? Patient to participate Patient views Past & present (written?) Beliefs and values Others views NOK Carers LPA or Deputy No motivation to end life Consultant decides Least restrictive care (DOLS) Court of protection if disagreements Will capacity return? Can we wait? Patient s current & previous views Other views Decision
Miss C has capacity
2005 Mental Capacity Act 1983 Mental Health Act
Refusing treatment Assess and record capacity Capacity No capacity Meets criteria for detention under MHA Does not meet criteria for detention MHA Best interests decision Intervene under MHA Record and communicate Least restrictive care (DOLS)
Mental Health Act 5 (2) 2 3 Section 63 Mental Health Act Assessement
Miss C is acutely depressed
Summary Sepsis NEWS Neutropenia Directory Ambulatory care MASCC Deliberate self harm Capacity Mental Health Act
I don t know but I know how to find out!
Hot topics in Acute Medicine Dr Ben Mearns FRCP Consultant Physician in Acute & Elderly Medicine Chief of Medicine Surrey & Sussex Healthcare NHS Trust @BenMearns ben.mearns@sash.nhs.uk