Following National Guidelines in Acute Care can improve emergency access and patient flow.

This paper describes how a Foundation Trust was able to meet emergency access targets. The Acute Medical Unit (AMU) was expanded from 29 to 81 beds and patients with expected length of stay (LOS( of less than 5 days were managed by the acute medical team only. Acute physicians provided twice-daily ward rounds on the expanded facility, including weekends, supported by specialist teams, allied healthcare professionals and investigation facilities. Within three weeks, the admission process had improved dramatically. Average LOS had decreased by 1.3 days and bed-occupancy was reduced from 98% to 91%. Having failed to achieve the 98% target for 4 consecutive months prior to these changes, the target was subsequently attained consistently. Re-admission rates, percentage mortality rate and numbers of complaints were unaffected.

Ketoacidosis is not always due to diabetes.

Chronic alcoholism is a frequently unrecognised cause of ketoacidosis. Most patients with alcoholic ketoacidosis present with normal or low glucose, but this condition can present with hyperglycaemia. This can lead to misdiagnosis of diabetes ketoacidosis and, therefore, inappropriate treatment with insulin. We describe a 37-year-old Caucasian woman with chronic pancreatitis secondary to excess alcohol consumption, admitted with abdominal pain and vomiting, fulfilling the criteria for diabetes ketoacidosis. She was treated according to diabetes ketoacidosis protocol and experienced a hypoglycaemic attack within an hour of initiation of insulin. On review of her history, she was found to have three similar episodes over the past 12 months. Alcoholic ketoacidosis can present with hyperglycaemia due to relative deficiency of insulin and relative surplus in counter-regulatory stress hormones including glucagon. Awareness of the syndrome with a detailed history helps to differentiate alcohol ketoacidosis from diabetes ketoacidosis and prevent iatrogenic hypoglycaemia.

Shingles with secondary asymptomatic CNS involvement!

A 32-year-old married Asian woman, previously fit and well, presented with a 3-day history of interscapular back pain followed by a 1-day history of frontal headache and a few episodes of vomiting. She did not have photophobia or neck stiffness. On examination, there was evidence of herpes zoster infection involving the right T3 dermatome. There were no signs of meningeal irritation, cognitive impairment or any neurological deficit. As it is uncommon to have reactivation of herpes zoster infection at a young age, HIV serology was requested to exclude immunodeficiency state. While awaiting serology, a lumbar puncture was performed to exclude opportunistic infections of the central nervous system as she had transient headache and vomiting at the onset. The cerebrospinal fluid showed an elevated level of protein, an increase in lymphocytes and a strongly positive PCR for varicella zoster. The HIV test was negative. Oral acyclovir was changed to intravenous therapy and, a week later, she was discharged with uneventful recovery.

Pulsatile abdominal mass is not always leaking aneurysm!

An 80-year-old male, who presented with a history of unprovoked collapse, was found to have a visible pulsation in the central upper abdomen, which disappeared on raising his arms above his shoulder ('head and shoulder' technique). There was no tenderness noted over the pulsation. He had a ventricular demand inhibited pacemaker inserted 3 weeks ago for a significant bradycardia with atrial fibrillation. His ECG showed heart rate of 32 bpm with underlying atrial fibrillation. No pacing spikes noted. His chest x-ray confirmed displacement of pacing lead into the right subclavian vein. It caused stimulation of phrenic nerve resulting in rhythmical diaphragmatic contraction. He later had his pacemaker re-inserted with no more collapses.