General internal medicine for PRES Level 2

An 80-year-old woman admitted with pneumonia becomes acutely confused overnight. She is disorientated in time and place, drowsy but rousable, with fluctuating attention. Her confusion was not present on admission. Oxygen saturation 93% on air, temperature 38.1°C. What is the most appropriate first step?

1. Arrange urgent CT brain Not first. Imaging is indicated for focal neurology, head injury, or delirium that fails to explain itself. Here there is a clear infective precipitant.
2. Apply physical restraints for her own safety Wrong. Restraint escalates agitation, risks injury, and raises serious legal and ethical problems.
3. Prescribe a benzodiazepine for sedation overnight Wrong, and likely to worsen things. Benzodiazepines prolong and deepen delirium, except in alcohol withdrawal where they are the treatment.
4. Identify and treat the underlying precipitants, and use non-pharmacological delirium measures correct Correct. This is delirium precipitated by infection and hypoxia. Management begins with finding and treating causes, infection, hypoxia, pain, constipation, urinary retention, drugs, plus reorientation, familiar faces, daylight, hearing aids and glasses.
5. Prescribe regular haloperidol Wrong as a first step. Antipsychotics are for the distressed or dangerous patient in whom non-drug measures have failed, at the lowest dose for the shortest time. They do not treat delirium and increase mortality in dementia.

The point: Delirium is acute, fluctuating and attention-based; diagnose clinically with 4AT or CAM. Treat the cause, optimise the environment, and reach for antipsychotics only for distress or danger that non-drug measures have not settled.

Source: NICE CG103 — Delirium: prevention, diagnosis and management NICE · tier 1, national regulator or guidance

A 62-year-old man on the ward becomes acutely breathless four days after a hemicolectomy. Heart rate 118, respiratory rate 28, oxygen saturation 89% on air, blood pressure 108/70 mmHg. Chest is clear, calves are non-tender. ECG shows sinus tachycardia. What is the most appropriate immediate action?

1. Treat as hospital-acquired pneumonia with intravenous antibiotics Wrong as the primary assumption. The chest is clear, there is no fever quoted, and the onset is sudden. Pneumonia does not typically present this abruptly with a clear chest.
2. Give oxygen, start therapeutic anticoagulation, and arrange urgent CT pulmonary angiography correct Correct. Postoperative day four with sudden hypoxic breathlessness, a clear chest and sinus tachycardia is pulmonary embolism until excluded. Treatment-dose anticoagulation should not wait for the scan when clinical probability is high and there is no contraindication.
3. Arrange an echocardiogram as the first investigation Wrong as first line. Echo is useful in a haemodynamically unstable patient who cannot be scanned, but a normal echo does not exclude pulmonary embolism.
4. Request a D-dimer to decide whether imaging is needed Wrong in this setting. D-dimer is elevated in essentially every patient four days after major surgery, so it has no discriminatory value and a raised result would not change management.
5. Give a fluid bolus and repeat observations in one hour Wrong. He is hypoxic and tachypnoeic, and an hour of observation in suspected pulmonary embolism is an hour of avoidable risk.

The point: Postoperative breathlessness with a clear chest is pulmonary embolism until proven otherwise. D-dimer is useless after surgery. Where clinical probability is high, anticoagulate first and image second, unless there is an active bleeding risk.

Source: NICE NG158 — Venous thromboembolic diseases: diagnosis, management and thrombophilia testing NICE · tier 1, national regulator or guidance

A 45-year-old man is admitted with severe epigastric pain radiating to the back, vomiting, and a serum lipase five times the upper limit of normal. He drinks heavily. On admission his heart rate is 116, blood pressure 104/64 mmHg and urine output is 15 mL/hour. What is the single most important early intervention?

1. Prophylactic broad-spectrum antibiotics Wrong. Prophylactic antibiotics in acute pancreatitis do not reduce mortality and select for resistant organisms and fungal infection. Antibiotics are for proven infected necrosis or another source.
2. Urgent CT abdomen on admission to assess for necrosis Wrong timing. Necrosis takes 72 hours or more to become apparent, so an admission CT underestimates severity and adds a contrast load to a hypovolaemic patient.
3. Immediate ERCP Wrong here. Urgent ERCP is indicated in gallstone pancreatitis with cholangitis or persistent biliary obstruction. This is alcohol-related and there is no evidence of obstruction.
4. Keep the patient nil by mouth for at least seven days with total parenteral nutrition Outdated. Early enteral feeding is preferred where tolerated because it maintains gut barrier integrity and reduces infectious complications compared with parenteral nutrition.
5. Aggressive intravenous fluid resuscitation with close monitoring of urine output correct Correct. Early goal-directed fluid resuscitation is the intervention with the greatest impact on outcome in acute pancreatitis, because third-space losses are large and hypovolaemia drives pancreatic necrosis and organ failure.

The point: Acute pancreatitis: fluids, analgesia, early enteral nutrition, treat the cause. No prophylactic antibiotics. Scan at 72 hours or later if the patient is not improving. Every patient needs an ultrasound to look for gallstones and a lipid profile.

Source: IAP/APA evidence-based guidelines for the management of acute pancreatitis IAP / APA (pancreatology) · tier 2, specialty society or college