An Unusual ED Case: Cardiac Tamponade Presenting as Hiccups

Cardiac tamponade is an emergent life threating condition that depending on cause can quickly progress to death. The rate of accumulation of a pericardial effusion often can determine the clinical severity. Typically, shortness of breath and hypotension manifest; however, in this unusual case, the initial presenting complaint was persistent hiccups

Assessment of acute abdomen in the emergency department

Acute abdominal pain is one of the most commonly encountered leading symptoms in the emergency department. Although it is oftentimes held for a purely surgical problem, two thirds of patients do not require operative management. The causative pathologies of the acute abdomen range from intra-abdominal to extra-abdominal and metabolic diseases. Therefore a multidisciplinary approach is imperative and early consultation is key in order not to unnecessarily delay treatment. Clinical experience is equally as important as a sound knowledge of the anatomy and physiology of the abdominal cavity and an understanding of the pathophysiological processes at work. This knowledge should be applied whilst taking a history and performing the physical examination. Investigative studies are indispensable in the evaluation of the acute abdomen, especially since at least one third of patients presents with atypical features. Thereby the age of the patient plays an important role. Elderly patients may present with signs and symptoms unimpressive to the untrained eye, yet harbouring a serious pathology. Laboratory tests by themselves are not enough to assess the patient, so radiological studies have to be a deeply rooted part of the patient evaluation. With ultrasonography, plain abdominal films, computed tomography, CT-angiography and magnetic resonance imaging a broad array of imaging modalities, are at the ED physician’s disposal. In choosing a modality the diagnostic yield of such a procedure should be weighed against the risk of radiation exposure. The severity of aetiologies ranges from benign self-limiting to life-threatening. Hence the main focus of the ED physician should be to triage the patient accordingly and discern whether immediate or urgent surgical intervention is necessary. Thereby a priority- and problem oriented strategy should be pursued. In order to prevent diagnostic errors and improve patient care, diagnostic algorithms and patient evaluation forms should be used

Assessment of acute abdomen in the emergency department

Acute abdominal pain is one of the most commonly encountered leading symptoms in the emergency department. Although it is oftentimes held for a purely surgical problem, two thirds of patients do not require operative management. The causative pathologies of the acute abdomen range from intra-abdominal to extra-abdominal and metabolic diseases. Therefore a multidisciplinary approach is imperative and early consultation is key in order not to unnecessarily delay treatment. Clinical experience is equally as important as a sound knowledge of the anatomy and physiology of the abdominal cavity and an understanding of the pathophysiological processes at work. This knowledge should be applied whilst taking a history and performing the physical examination. Investigative studies are indispensable in the evaluation of the acute abdomen, especially since at least one third of patients presents with atypical features. Thereby the age of the patient plays an important role. Elderly patients may present with signs and symptoms unimpressive to the untrained eye, yet harbouring a serious pathology. Laboratory tests by themselves are not enough to assess the patient, so radiological studies have to be a deeply rooted part of the patient evaluation. With ultrasonography, plain abdominal films, computed tomography, CT-angiography and magnetic resonance imaging a broad array of imaging modalities, are at the ED physician’s disposal. In choosing a modality the diagnostic yield of such a procedure should be weighed against the risk of radiation exposure. The severity of aetiologies ranges from benign self-limiting to life-threatening. Hence the main focus of the ED physician should be to triage the patient accordingly and discern whether immediate or urgent surgical intervention is necessary. Thereby a priority- and problem oriented strategy should be pursued. In order to prevent diagnostic errors and improve patient care, diagnostic algorithms and patient evaluation forms should be used

A clinical study of upper gastrointestinal endoscopy findings in patients presenting with dyspepsia

INTRODUCTION: Dyspepsia is affecting about 25% of general population in developed nations and it is a major cause for medical visits. New patients comprise about 10% of population every year. Dyspepsia majorly affects quality of life and it is a major burden in view of social costs. Directly the expenses are for laboratory tests, medical consultation and drugs and indirectly by absence from work. Dyspepsia refers to spectrum of diseases and heterogeneous group of symptoms confined to upper abdomen. Dyspepsia is a vague term used to explain upper abdominal collection of symptoms like indigestion, fullness, early satiety (not able to complete the meals), bloating, belching, nausea, epigastric discomfort or pain and anorexia. Indigestion is very common in general population; almost all have had indigestion at some time in their lifetime. Sometimes patients will include constipation and undigested food particles in the stool. Rome II working team defined dyspepsia as discomfort or pain in upper abdomen. Central abdominal pain is considered to be a vital symptom. Pain which is present in other regions or associated to defecation is not considered. Non ulcer dyspepsia, this description comprises a group of symptom complex simulating peptic ulcer in patients who have no provable or objective evidence of an ulcer. Based on analysis of problems individuals with non ulcer dyspepsia categorized into two types. Pseudo ulcer syndrome—with classic symptoms of ulcer disease Functional dyspepsia—with post prandial fullness, belching and bloating, occasionally associated with pyloroduodenal irritability and prolonged gastric emptying. Usually this functional component is attributed to uncoordinated motor activity and afferent hyper reactivity. Gastro-oesophageal reflux disease is a condition, defined as abnormal entering of gastric juice into oesophagus and causes symptoms due to tissue damage. The principal pathophysiological problem is the presence of unusual amount of gastric juice in the lumen of oesophagus. Symptoms thought to suggest of gastro-oesophageal disease , such as heart burn or regurgitation are very much prevalent in general population and many individuals do not seek medical advice. The presence of symptoms doesn’t correlate well with the tissue damage. For instance the significant problem like Barrett’s oesophgus, even in early adenocarcinoma, can occur without symptoms. Gastro-oesophageal reflux disease is most commonly treated by physicians, this is substantiated by amount of revenue recorded by many pharmacteutical company. The symptoms are due to failure of protective antireflux mechanisms. A clear understanding of the normal anatomy and physiology of esophagus is mandatory to decide the surgical and medical management. OBJECTIVES: 1. To study the endoscopic presentation of dyspepsia. 2. Early detection of esophagogastroduodenal carcinoma. 3. To study the age and sex prevalence in patients presenting with dyspepsia. 4. To study the common site of lesion in patients presenting with dyspepsia. METHODOLOGY: A prospective clinical study was undertaken at Tirunelveli Medical College Hospital, Tirunelveli to know the various upper gastro-intestinal endoscopic findings in patients presenting with dyspepsia. The study was conducted from march 2011 to October 2012. The patient selection was by convenience sampling. Dyspeptic patients were included in this study with their informed consent. A detailed clinically history was elucidated, followed by careful clinical examination, which were recorded as per the proforma. All the patients included in the study underwent upper gastrointestinal endoscopy and the findings were noted. The inclusion and exclusion criterias were as follows: Inclusion criteria: 1. Patients above 13 years of age. 2. Patients showing symptoms of dyspepsia for 4 or more than 4 weeks. 3. Patients with uncomplicated and uninvestigated dyspepsia. Exclusion criteria: 1. Patients below 10 years of age. 2. Pregnant and lactating women. 3. Patients on proto-pump inhibitors. 4. Patients who are known cases of chronic pancreatitis and liver disease. 5. Patients on NSAID’s for more than one month duration. 6. Unwilling or unfit patients for endoscopy. SUMMARY A prospective clinico-pathological study was undertaken in Tirunelveli Medical College Hospital to know the various endoscopic findings in patients presenting with dyspepsia and early detection of oesophagogastroduodenal malignancy in these patients. 140 patients presenting with dyspepsia were evaluated. The following were the observations: 1. Highest prevalence of dyspepsia in the age group of 30-39years. 2. Most common presenting complaint was epigastric pain and discomfort. 3. Dyspepsia was more common in males (58%) when compared to Females (42%) 4. Most common endoscopic finding was normal study followed by gastritis. 5. Malignancy was diagnosed in 5.7% patients with dyspepsia. 6. Stomach is the common site of lesion in patients presenting with dyspepsia 7. Gastritis, duodenitis and gastric ulcer is common in males while malignancy/growth is more common in females presenting with dyspepsia. 8. Incidence of malignancy increases as the age advances. CONCLUSION: From the present study of “A clinical study of various findings in upper gastro-intestinal endoscopy in patients presenting with dyspepsia”. On endoscopic examination gastritis accounted for the majority of the cases. Incidence of malignancy in the present study was observed to be 5.7% (gastric malignancies). Clinically significant endoscopic findings were observed in 52.14% of patients with uninvestigated dyspepsia. Most patients presented with a complex of three or more dyspeptic symptoms and the symptom profile was not predictive of the endoscopic findings. Prevalence of large number of inflammatory lesions as a result of increased acid production and low incidence of malignancy in the study group suggests that the uninvestigated patients with dyspepsia may be initially managed medically with acid suppressive therapy

Medical-Data-Models.org:A collection of freely available forms (September 2016)

MDM-Portal (Medical Data-Models) is a meta-data repository for creating, analysing, sharing and reusing medical forms, developed by the Institute of Medical Informatics, University of Muenster in Germany. Electronic forms for documentation of patient data are an integral part within the workflow of physicians. A huge amount of data is collected either through routine documentation forms (EHRs) for electronic health records or as case report forms (CRFs) for clinical trials. This raises major scientific challenges for health care, since different health information systems are not necessarily compatible with each other and thus information exchange of structured data is hampered. Software vendors provide a variety of individual documentation forms according to their standard contracts, which function as isolated applications. Furthermore, free availability of those forms is rarely the case. Currently less than 5 % of medical forms are freely accessible. Based on this lack of transparency harmonization of data models in health care is extremely cumbersome, thus work and know-how of completed clinical trials and routine documentation in hospitals are hard to be re-used. The MDM-Portal serves as an infrastructure for academic (non-commercial) medical research to contribute a solution to this problem. It already contains more than 4,000 system-independent forms (CDISC ODM Format, www.cdisc.org, Operational Data Model) with more than 380,000 dataelements. This enables researchers to view, discuss, download and export forms in most common technical formats such as PDF, CSV, Excel, SQL, SPSS, R, etc. A growing user community will lead to a growing database of medical forms. In this matter, we would like to encourage all medical researchers to register and add forms and discuss existing forms

The Shared Genetic Architecture of Modifiable Risk for Dementia and its Influence on Brain Health

Targeting modifiable risk factors for dementia may prevent or delay dementia. However, the mechanisms by which risk factors influence dementia remain unclear and current research often ignores commonality between risk factors. Therefore, my thesis aimed to model the shared genetic architecture of modifiable risk for dementia and explored how these shared pathways may influence dementia and brain health. I used linkage disequilibrium score regression and genomic structural equation modelling (SEM) to create a multivariate model of the shared genetics between Alzheimer’s disease (AD) and its modifiable risk factors. Although AD was genetically distinct, there was widespread genetic overlap between most of its risk factors. This genetic overlap formed an overarching Common Factor of general modifiable dementia risk, in addition to 3 subclusters of distinct sets of risk factors. Next, I performed two multivariate genome-wide association studies (GWASs) to identify the risk variants that underpinned the Common Factor and the 3 subclusters of risk factors. Together, these uncovered 590 genome-wide significant loci for the four latent factors, 34 of which were novel findings. Using post-GWAS analyses I found evidence that the shared genetics between risk factors influence a range of neuronal functions, which were highly expressed in brain regions that degenerate in dementia. Pathway analysis indicated that shared genetics between risk factors may impact dementia pathogenesis directly at specific loci. Finally, I used Mendelian randomisation to test whether the shared genetic pathways between modifiable dementia risk factors were causal for AD. I found evidence of a causal effect of the Common Factor on AD risk. Taken together, my thesis provides new insights into how modifiable risk factors for dementia interrelate on a genetic level. Although the shared genetics between modifiable risk factors for dementia seem to be distinct from dementia pathways on a genome-wide level, I provide evidence that they influence general brain health, and so they may increase dementia risk indirectly by altering cognitive reserve. However, I also found that shared genetics risk between risk factors in certain genomic regions may directly influence dementia pathogenesis, which should be explored in future work to determine whether these regions represent targets to prevent dementia

College and Clinical Record

Published from 1880-1899, the College and Clinical Record was a monthly medical journal put out by Jefferson Medical College students and graduates. It commonly included printed lectures, conference proceedings, original articles, reminiscences, obituaries notices, marriage announcements, and college news. According to its first publication, The CLINICAL RECORD has been instituted more particularly for the purpose of conveying to those interested the most reliable intelligence of current affairs at the Jefferson Medical College, and of furnishing a means of intercourse between graduates of the school... It is especially intended to impart to the graduates and students of the College accurate and elaborate reports of the medical, surgical, and gynaecological clinics held by the members of the Faculty and Hospital Staff, with notes of peculiarities of treatment of cases in the hospital of the College. The editors are two of its graduates, who are keenly sensible of the desirability of preserving as much as possible of the valuable instruction of the \u27Old Jeff,\u27 as it is familiarly known.https://jdc.jefferson.edu/jmc_publications/1000/thumbnail.jp