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Hepatitis

Essentials 1 Acute and chronic viral hepatitis is of global public health importance. 2 Definitive diagnosis may be delayed in the emergency setting. 3 Supportive care is fundamental in the acute management of hepatitis. 4 Prevention of viral hepatitis is possible via the introduction of public health programmes that include appropriate education regarding high-risk practices. Introduction Hepatitis is a non-specific clinicopathological term that encompasses all disorders…

Skin and soft-tissue infections

Essentials 1 The time-honoured principles of soft tissue infection management and judicious evidence-based use of antibiotics remain the basis of treatment and the prevention of further complications. 2 These infections are common and range from mild to rapidly progressive and life threatening; early clinical recognition and treatment are paramount in reducing morbidity and mortality. 3 Deep soft tissue infections have high morbidity and mortality and, unless…

Urinary tract infections

Essentials 1 Urinary tract infection (UTI) is the most common bacterial infection. 2 By age 32, 50% of women will report at least one UTI. 3 Sexual activity is the most important risk factor in young women. 4 Most UTIs are caused by Escherichia coli , but Staphylococcus saprophyticus is responsible for up to 15% of infections in young, sexually active women. 5 There is a…

Septic arthritis

Essentials 1 Early diagnosis and treatment are critical for the prevention of irreversible joint destruction. 2 Diagnosis is based on clinical features and synovial fluid examination; imaging techniques have a role in difficult cases. 3 Staphylococcus aureus, Streptococcus and Neisseria gonorrhoeae are the most frequent pathogens in adults and older children. Methicillin-resistant staphylococcus aureus (MRSA) is an emerging problem, particularly among intravenous drug users. Fungal, mixed…

Meningitis

Essentials 1 Bacterial meningitis can be a rapidly progressive and fatal illness. A high level of suspicion is necessary, as well as rapid diagnosis and treatment. 2 Eighty-five percent of cases have headache, fever, meningism and mental obtundation, but these are often absent or diminished in very young or old patients, those partially treated with oral antibiotics and those with some form of immunocompromise. 3 Treatment…

Approach to undifferentiated fever in adults

Essentials 1 Over one-third of patients who have fever for more than 2 to 3 days with no localizing symptoms and signs are likely to have a bacterial infection; half of these will be in the respiratory or urinary tracts. 2 An unexplained fever in a person over the age of 50 should be regarded as due to a bacterial infection until proved otherwise. 3 An…

Weakness

Essentials 1 The differential diagnosis of weakness in the emergency department (ED) is very broad. Careful history taking and examination with targeted investigations will help to identify most of the important causes. 2 Causes of weakness must be distinguished as neuromuscular or non-neuromuscular. 3 Most patients presenting to the ED with a complaint of weakness have a non-neuromuscular cause for their symptoms. 4 Guillain-Barré syndrome is…

Syncope and vertigo

Essentials 1 It is important to distinguish between syncope and true vertigo. 2 The most common cause of syncope is neurally mediated syncope. 3 A detailed history and physical examination are more useful than extensive investigations. 4 It is essential to identify high-risk patients for the serious potential cardiac causes of syncope so that appropriate treatment can be given. 5 A key diagnostic step is to…

Seizures

Essentials 1 Approximately 9% of the population will have at least one seizure in their lifetimes but only 1% to 3% will develop epilepsy. 2 The management of an acute episode is directed at rapid control of seizures, identification of precipitating factors and prevention/correction of complications. 3 Benzodiazepines and phenytoin are the principal anticonvulsant agents for acute seizures. 4 Management of drug-related seizures (including those related…

Altered conscious state

Essentials 1 For clinical purposes, the ability of the individual to respond appropriately to environmental stimuli provides a quantifiable definition of consciousness. 2 The causes of altered conscious state can be divided pathophysiologically into structural and metabolic insults. 3 A thorough history and examination is the key to guiding investigation choice and identifying the cause of the primary insult. Management is directed towards resuscitation, specific correction…

Subarachnoid haemorrhage

Essentials 1 The diagnosis of subarachnoid haemorrhage (SAH) requires a high index of suspicion. 2 Up to a third of patients with SAH experience a warning leak—the sentinel haemorrhage—in the hours to days prior to the major bleed. 3 Risk of re-bleeding is maximal in first 2 to 12 hours and is associated with a poor prognosis and high mortality. 4 Severe sudden headache is the…

Stroke and transient ischaemic attacks

Essentials 1 Ischaemic strokes and transient ischaemic attacks (TIAs) are most commonly due to atherosclerotic thromboembolism of the cerebral vasculature or emboli from the heart. Other causes should be considered in younger patients, those presenting with atypical features or when evaluation is negative for the more common aetiologies. 2 Haemorrhagic and ischaemic strokes cannot be reliably differentiated on clinical grounds alone; therefore further imaging, most commonly…

Headache

Essentials 1 The pathophysiological basis of headache is understood to be traction or inflammation of extracranial structures, the basal dura or the large intracranial arteries and veins, dilatation/distension of cranial vascular structures or activation/sensitization of perivascular nerves. 2 Severity of headache is not a reliable indicator of the underlying pathology. 3 History is of paramount importance in the assessment of headache. 4 A normal physical examination…

Perianal conditions

Essentials 1 Anal pain, bleeding and masses are common symptoms in many different types of anorectal pathology. A careful history and anorectal examination are important in making the correct diagnosis. 2 Increasing fibre intake and reducing constipation are effective initial treatments for mild, uncomplicated haemorrhoidal disease and perianal fissures. 3 Anorectal abscesses require incision and drainage. In some cases, this can be done safely in the…

Haematochezia

Essentials 1 Haematochezia is a common presentation in patients aged over 50 years and can result in shock due to large-volume blood loss. 2 The most common cause of lower gastrointestinal bleeding (LGIB) in younger patients (<50 years of age) is anorectal disorders. In elderly patients, diverticular disease is the main cause. 3 Most cases of lower gastrointestinal (GI) haemorrhage are self-limiting and resolve spontaneously. 4…

Acute liver failure

Essentials 1 The diagnosis of acute liver failure (ALF) is based on the presence of worsening coagulopathy, hepatic encephalopathy and deepening jaundice. 2 In developing countries, viral causes predominate, with hepatitis E infection recognized as a common cause in many countries. 3 In developed countries, drug-induced liver injury (DILI) predominates, often from paracetamol. 4 Diagnosis of ALF must be considered in anyone presenting with the recent…

Inflammatory bowel disease

Essentials 1 The two major forms of inflammatory bowel disease (IBD) are Crohn’s disease and ulcerative colitis. The principal clinical features are diarrhoea and/or abdominal pain. 2 IBD is a chronic and relapsing condition. Patients may present to the emergency department with increased disease activity or with complications of the disease process or treatment. 3 Gastrointestinal complications may include dehydration, bleeding, strictures, obstruction, fistulae, sepsis, perforation,…

Acute appendicitis

Essentials 1 Appendicitis is the commonest cause of acute abdominal pain requiring surgical treatment. 2 The diagnosis is primarily clinical, but the absence of a pathognomonic sign or conclusive first-line diagnostic test can cause diagnostic difficulty. 3 Diagnostic delay is the primary cause of morbidity and mortality and a major source of litigation related to medical negligence in emergency departments. 4 Specialized imaging techniques enhance diagnostic…

Acute pancreatitis

Introduction The twin challenges of acute pancreatitis are to establish the diagnosis and stratify severity. The difficulty in diagnosing pancreatitis lies in its non-specific symptomatology, which is shared by a number of other gastrointestinal diseases. The 2012 revised Atlanta classification definition of acute pancreatitis requires two of the following three features: (1) abdominal pain consistent with acute pancreatitis; (2) serum lipase or amylase activity equal to…

Biliary tract disease

Essentials 1 More than 95% of biliary tract disease is attributable to gallstones. 2 Most patients with gallbladder disease present with abdominal pain. 3 Investigations are directed to confirming the diagnosis and detecting the presence of complications. 4 The management of acute biliary pain (biliary colic) is supportive and discharge from the Emergency Department is often possible. 5 The management of cholecystitis and other complications of…