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41. Organophosphate poisoning

, parathion) or nerve agents (e.g., tabun, sarin), causing inhibition of acetylcholinesterase at nerve synapses. The term organophosphate poisoning only applies to those organophosphates that inhibit acetylcholinesterase. This topic focuses on pesticide poisoning. History and exam presence of risk factors increased secretions fasciculations pinpoint pupils distinctive odour chest crackles and rhonchi semi-conscious/coma visual disturbances vomiting influenza-like syndrome urinary or faecal incontinence

2018 BMJ Best Practice

42. Volume depletion in adults

, thirst, impaired sensorium, and, in more extreme cases, coma or seizures. By contrast, clinical symptoms of volume depletion are a result of the haemodynamic effects of the reduction in intravascular volume and usually do not involve neurological changes. History and exam postural dizziness weight loss orthostatic hypotension postural tachycardia signs of shock decreased urine output diarrhoea vomiting melaena haematochezia high-volume GI drainage polyuria poor oral intake severe sweating burns

2018 BMJ Best Practice

43. Cryptococcosis

, such as those with HIV. Occasionally, people with no apparent immune-system problems develop cryptococcosis, particularly Cryptococcus var. gattii . History and exam presence of risk factors constitutional symptoms dyspnoea productive cough dullness to percussion diminished breath sounds crackles headache alteration of consciousness meningeal irritation papilloedema skin lesions coma chest pain cranial neuropathy ocular manifestations HIV infection immunosuppression comorbidities and smoking exposure

2018 BMJ Best Practice

44. Ehrlichiosis and anaplasmosis

type are generally the same. This monograph deals with human infection only. History and exam presence of risk factors fever headache malaise myalgia arthralgia nausea small erythematous lesion with or without necrotic centre non-specific rash vomiting diarrhoea abdominal pain cough dyspnoea stiff neck confusion photophobia stupor coma seizures lymphadenopathy jaundice hepatomegaly splenomegaly secondary infections tick bite/exposure immunosuppression age over 60 years male sex Diagnostic

2018 BMJ Best Practice

45. Rabies

countries including the US. The World Health Organization (WHO) has set a global goal to achieve no human deaths from dog-transmitted rabies by 2030. World Health Organization. Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030. June 2018 [internet publication]. History and exam presence of risk factors hydrophobia aerophobia limb numbness, pain, and paraesthesia pruritus dysphagia fever change in behaviour (...) agitation and confusion hallucination signs of autonomic instability rapid progression of symptoms weakness and paralysis urinary or faecal incontinence coma abdominal pain insomnia seizures slurred or stuttered speech ataxia recent scratch or bite from a known vector travel to/living in rabies-endemic country occupational or recreational exposure age <15 years Diagnostic investigations saliva PCR and viral culture skin biopsy (neck) with direct fluorescent antibody (DFA) and PCR CSF cytology CSF

2018 BMJ Best Practice

46. Lead toxicity

level is consistent with exposure to lead, but levels >0.4 micromoles/L (>9 micrograms/dL) in a child or >1.2 micromoles/L (>24 micrograms/dL) in an adult are currently considered to require active interventions. Toxicity occurs at lower levels, but prevention is the approach to preventing such toxicity in the absence of effective management options at such levels. History and exam presence of risk factors FHx of lead poisoning or parental work with lead cognitive impairment (children) behavioural (...) changes (children) headaches (children) clumsiness and agitation (children) loss of appetite (children) constipation (children) somnolence (children) altered mental state cerebellar signs seizures coma colicky abdominal pain (adults) hypertension (adults) age 9 to 36 months housing with lead hazards occupational lead exposure lead-contaminated water supplies low socioeconomic status hobbies working with lead pica use of folk medications fetal exposure mineral-deficient and high-fat diets hand-to-mouth

2018 BMJ Best Practice

47. Ischaemic stroke This replaced the former definition of focal neurological impairment lasting less than 24 hours. History and exam vision loss or visual field deficit weakness aphasia impaired co-ordination (ataxia) history of transient ischaemic attack (TIA) sudden onset of symptoms negative symptoms (i.e., loss of function) altered sensation headache diplopia sensory loss dysarthria gaze paresis arrhythmias, murmurs, or pulmonary oedema vertigo/dizziness nausea and/or vomiting neck or facial pain miosis (...) , ptosis, and facial anhidrosis (hemilateral) altered level of consciousness/coma confusion older age family history of stroke history of ischaemic stroke hypertension smoking diabetes mellitus atrial fibrillation comorbid cardiac conditions carotid artery stenosis sickle cell disease dyslipidaemia people with lower levels of education African-American or Hispanic ancestry poor diet and nutrition physical inactivity obesity alcohol abuse oestrogen-containing therapy illicit drug use migraine

2018 BMJ Best Practice

48. South American haemorrhagic fevers

. Viral hemorrhagic fevers (VHFs): Old World/New World arenaviruses. June 2013 [internet publication]. History and exam presence of risk factors fever ≥37.5°C bleeding (gums, epistaxis, gastrointestinal, metrorrhagia) petechiae conjunctivitis malaise headache arthralgia myalgia abdominal pain nausea/vomiting diarrhoea lymphadenopathy neurological symptoms (e.g., confusion, ataxia, seizures) sore throat cough prostration/coma occupational exposure

2018 BMJ Best Practice

49. Lassa fever

and death. History and exam presence of risk factors fever ≥37.5°C elevated respiratory rate low systolic blood pressure malaise nausea/vomiting headache sore throat/pharyngitis conjunctivitis chest pain/cough myalgia deafness (sensorineural) facial oedema bleeding abdominal pain diarrhoea confusion and altered Glasgow Coma Scale or seizures effusions occupational exposure living/working in, or arrival from, endemic area contact with infected body fluids butchering and/or eating rodent meat bioterrorism

2018 BMJ Best Practice

50. Hyponatraemia

of hyponatraemia.) This topic principally focuses on hypotonic (hypo-osmolar) hyponatraemia, the most common type of hyponatraemia. History and exam presence of risk factors high fluid intake fluid losses history of diabetes mellitus history of cirrhosis, nephrosis, congestive heart failure nausea/vomiting mild cognitive symptoms altered mental status, seizures, coma low urine output weight changes orthostatic hypotension abnormal jugular venous pressure poor skin turgor dry mucous membranes absence

2018 BMJ Best Practice

51. Primary hypothyroidism

Med. 2001;345:260-265. Myxoedema coma is a rare severe form of hypothyroidism with multi-organ failure. Franklyn JA. Hypothyroidism. Medicine. 2005;33:27-29. History and exam presence of risk factors weakness lethargy cold sensitivity constipation weight gain depression menstrual irregularity myalgia dry or coarse skin eyelid oedema thick tongue facial oedema coarse hair bradycardia deep voice diastolic hypertension with or without

2018 BMJ Best Practice

52. Acute aspiration

:818-826. This topic does not discuss the inhalation of foreign bodies. History and exam presence of risk factors intractable cough fever dyspnoea wheezing crackles decreased level of consciousness (Glasgow coma scale score <9) increased severity of illness general anaesthesia age >70 years male sex head trauma cerebrovascular disease endotracheal or tracheostomy tube dysphagia airway difficulties barium meal gastro-oesophageal

2018 BMJ Best Practice

53. Rocky Mountain spotted fever Detailed content on other rickettsial infections is covered by our separate Rickettsial Diseases topic. History and exam known recent tick exposure or bite triad of fever, rash, and history of tick exposure triad of fever, rash, and headache fever rash headache nausea/vomiting myalgia altered mental status abdominal pain residence in or recent exposure to rural area diarrhoea conjunctivitis lymphadenopathy peripheral oedema meningismus splenomegaly hepatomegaly jaundice seizures shock coma

2018 BMJ Best Practice

54. Abusive head trauma in infants

head trauma in young children in the Netherlands: evidence for multiple incidents of abuse. Acta Paediatr. 2013 Nov;102(11):e497-501. History and exam presence of risk factors age <3 years altered mental status: irritability/lethargy/coma clinical findings inconsistent with carer history retinal/vitreal haemorrhages or retinoschisis no known history of trauma apnoea seizure vomiting loss of muscle tone brisk or asymmetrical reflexes

2018 BMJ Best Practice

55. Electrical injury

no injury. May cause electrical and thermal burns, and secondary injuries due to a fall, severe tetany, or the force of electrical blast. Survivors of high-voltage electrical injury or lightning strikes can suffer long-term sequelae, and regular follow-up is essential. Definition Electrical injuries may be caused by exposure to natural lightning or electricity in the home or workplace. Electrical injury includes electrocution, electric shock, burns, and secondary injuries. History and exam presence (...) of risk factors loss of consciousness pre-hospital CPR or defibrillation tachycardia hypotension low Glasgow coma score burns physical injuries diminished peripheral pulses and poor capillary refill low core body temperature confusion paralysis age <6 years construction industry workers male Diagnostic investigations ECG FBC electrolytes LFTs coagulation studies CK urine myoglobin cardiac enzymes (CK-MB and troponin) toxicology screen CXR plain x-rays head CT head MRI Treatment algorithm ACUTE

2018 BMJ Best Practice

56. Hypothermia

normal limits, typically <35°C (<95°F). History and exam presence of risk factors cold exposure and body temperature <35°C (<95°F) impaired mental state shivering frostbite tachypnoea, tachycardia, hypertension if mild hypothermia respiratory depression, bradycardia, hypotension if moderate hypothermia coma and apnoea if severe hypothermia cold-induced diuresis general anaesthetic use substance abuse impaired mental status hypothyroidism stroke Parkinson's disease neuroleptic medication beta-blocker

2018 BMJ Best Practice

57. Hypercalcaemia of malignancy

Jan 27;352(4):373-9. Horwitz MJ, Hodak SP, Steward AF. Non-parathyroid hypercalcemia. In: Rosen CJ, ed. Primer on the metabolic bone diseases and disorders of mineral metabolism. 8th ed. Washington, DC: American Society of Bone and Mineral Research; 2013:562-71. History and exam presence of risk factors history of malignancy normal physical exam poor skin turgor and/or dry mucous membranes confusion fatigue constipation loss (...) of appetite nausea polyuria polydipsia bone pain use of hypercalcaemia-inducing medication stupor coma non-metastatic malignancy metastatic skeletal involvement lymphoma Diagnostic investigations total serum calcium serum ionised calcium serum albumin comprehensive metabolic panel resting ECG serum intact parathyroid hormone serum parathyroid hormone-related peptide serum phosphorus serum calcitriol (1,25-dihydroxyvitamin D) serum 25-hydroxyvitamin D skeletal survey chest x-ray Treatment algorithm ACUTE

2018 BMJ Best Practice

58. Guidelines on Diagnosis and Management of Syncope

not lost in carotid TIAs, but there are pronounced focal neurological signs and symptoms Subclavian steal syndrome Associated with focal neurological signs Metabolic disorders including hypoglycaemia, hypoxia, hyperventilation with hypocapnia Duration much longer than in TLOC; consciousness may be impaired instead of lost Intoxication Duration much longer than in TLOC; consciousness may be impaired instead of lost Cardiac arrest LOC yet no spontaneous recovery Coma Duration much longer than TLOC (...) hypoglycaemia, hypoxia, hyperventilation with hypocapnia Duration much longer than in TLOC; consciousness may be impaired instead of lost Intoxication Duration much longer than in TLOC; consciousness may be impaired instead of lost Cardiac arrest LOC yet no spontaneous recovery Coma Duration much longer than TLOC LOC = loss of consciousness; PPS = psychogenic pseudosyncope; TIA = transient ischaemic attack; TLOC = transient loss of consciousness. Table 4 Conditions that may be incorrectly diagnosed

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2018 European Society of Cardiology

59. Appropriate Use Criteria: Imaging of the Brain

-to-peer conversation include: ? CT brain and CT sinus for headache ? MRI brain and MRA brain for headache ? MRI cervical spine and MRI shoulder for pain indications ? MRI lumbar spine and MRI hip for pain indications ? MRI or CT of multiple spine levels for pain or radicular indications ? MRI foot and MRI ankle for pain indications ? Bilateral exams, particularly comparison studies There are certain clinical scenarios where simultaneous ordering of multiple imaging studies is consistent with current (...) the guidelines for specific imaging exams is a determination that the following are true with respect to the imaging request: ? A clinical evaluation has been performed prior to the imaging request (which should include a complete history and physical exam and review of results from relevant laboratory studies, prior imaging and supplementary testing) to identify suspected or established diseases or conditions. ? For suspected diseases or conditions: o Based on the clinical evaluation, there is a reasonable

2019 AIM Specialty Health

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