Un hallazgo inesperado en hipocondrio derecho / An unexcepted finding in the right hypocondrium

A 90-years-old man comes to the emergency department with diffuse abdominal pain and fever three days. On physical examination, the abdomen is soft and depressible with air-fluid sound present and bilateral reductible inguinal hernias. A mass is palpated at the level of the roght hypochondrium with a positive Murphy´s sign whitout signs of peritoneal irritation. An abdominal CT with intravenous contrast is requested due to the suspicion of acute abdominal pathology, observing cholelithiasis and a markedly distended gallbladder with torsion. (AU)

Quiste complejo de mama / Complex cyst of the breast

83-year-old woman with palpable lesion on the left breast. Mammography shows a single nodule with well-defined borders, and ultrasound a complex cyst with solid areas that biopsy resulted in an encapsulated papillary breast carcinoma. Two axillary lymph nodes were affected. (AU)

Bulto y molestias en región inguinal en gestante de 16 semanas / Lump and discomfort in the groin region in a 16-week pregnant woman 16 weeks

34-year-old woman, 16 weeks pregnant, with a personal history of cervical conization and previous cesarean section.Consultation for discomfort in the right groin region and signs of inflammation in the area, without a clear tumor. She refers that inthe first pregnancy she presented the same symptoms. In the intergestational period she has not noticed these symptoms. On physicalexamination, the 16-week pregnant abdomen did not reveal clear signs of hernia, although there was slight pain on palpation. It wasdecided to request a pelvic ultrasound to rule out the presence of hernia or other soft tissue lesions in the groin region. (AU)

Mujer de 34 años, gestante de 16 semanas, con antecedentes personales de conización cervical y cesárea anterior. Consultapor molestias en región inguinal derecha y signos de inflamación en la zona, sin clara tumoración. Refiere que en el primerembarazo presentaba la misma sintomatología. En el período intergestacional no ha notado estos síntomas. A la exploraciónfísica se palpa útero, con altura correspondiente a unas 16 semanas de gestación, no se demuestran signos evidentes de hernia,aunque si leve dolor a la palpación. Se decide solicitar ecografía pélvica para descartar la presencia de hernia u otras lesiones de partes blandas en región inguinal. (AU)

Proctitis estercorácea. Una entidad potencialmente mortal / Stercoraceus proctitis. A potentially deadly entity

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77 years old man with abdominal pain, vomiting, and oral intolerance. History of chronic constipation. Abdominal CT shows dilatation and wall thickening of sigmoid and rectum . Stercoraceus colitis is a rare but serious disease and can cause death

Enfermedad neurodegenerativa: demencia frontotemporal / Neurodegenerative disease: Frontotemporal dementia

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Lesión atípica del cuerpo calloso / Atypical lesion of the corpus callosum

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Labor asistencial del equipo de guardia de neurología en un hospital terciario de Madrid: análisis prospectivo durante un año / Workload of on-call emergency room neurologists in a Spanish tertiary care centre. A one-year prospective study

Introducción: El envejecimiento poblacional, el aumento en la demanda asistencial y la instauración de tratamientos avanzados para el ictus agudo han originado que las urgencias neurológicas crezcan en número y complejidad. A pesar de esto, muchos centros hospitalarios de España carecen de guardias específicas de Neurología. Métodos: Estudio prospectivo durante un año (agosto 2010-julio 2011), que describe la labor asistencial del equipo de guardia de Neurología del Hospital terciario Gregorio Marañón de Madrid. Se recogieron las características sociodemográficas, las principales afecciones, las pruebas diagnósticas y el flujo de los pacientes atendidos, utilizando un registro diario mediante una base de datos informatizada. Los resultados fueron comparados con la asistencia médica general en urgencias. Resultados: Se atendió a 3.234 pacientes (3,48% del total de urgencias médicas), con una media de 11,15 pacientes/día. La edad media fue de 59 años. Las enfermedades más frecuentes fueron la cerebrovascular (34%), epilepsia (16%) y cefalea (8%). La estancia media en urgencias fue de 7,17 h. La tasa de ingreso hospitalario fue del 40% (7,38% del total de ingresos urgentes por afección médica). Los principales destinos de los pacientes hospitalizados fueron Unidad de Ictus (39,5%) y la planta de Neurología (33%). Se realizaron 76 procedimientos trombolíticos o intravasculares en ictus agudos. El 70% de los pacientes fue valorado fuera del horario laboral. Conclusiones: La atención neurológica es frecuente, variada y compleja, representando un alto porcentaje sobre el total de paciente atendidos o ingresados en urgencias. Nuestros resultados justifican la presencia física de un neurólogo de guardia 24 h en urgencias

Introduction: Population ageing, the rising demand for healthcare, and the establishment of acute stroke treatment programs have given rise to increases in the number and complexity of neurological emergency cases. Nevertheless, many centres in Spain still lack on-call emergency neurologists. Methods: We conducted a retrospective study to describe the role of on-call neurologists at Hospital General Universitario Gregorio Marañon, a tertiary care centre in Madrid, Spain. Sociodemographic characteristics, most common pathologies, diagnostic tests, and destination of the patients attended were recorded daily using a computer database. Results were compared with the general care data from the emergency department. Results: The team attended 3234 patients (3.48% of the emergency department total). The mean number of patients seen per day was 11.15. The most frequent pathologies were stroke (34%), epilepsy (16%) and headache (8%). The mean stay in the emergency department was 7.17 hours. Hospital admission rate was 40% (7.38% of emergency hospital admissions). The main destinations for admitted patients were the stroke unit (39.5%) and the neurology department (33%). Endovascular or thrombolytic therapies were performed on 76 occasions. Doctors attended 70% of the patients during on-call hours. Conclusions: Emergency neurological care is varied, complex, and frequently necessary. Neurological cases account for a sizeable percentage of both patient visits to the emergency room and the total number of emergency admissions. The current data confirm that on-call neurologists available on a 24-hour basis are needed in emergency departments

Workload of on-call emergency room neurologists in a Spanish tertiary care centre. A one-year prospective study.

INTRODUCTION: Population ageing, the rising demand for healthcare, and the establishment of acute stroke treatment programs have given rise to increases in the number and complexity of neurological emergency cases. Nevertheless, many centres in Spain still lack on-call emergency neurologists. METHODS: We conducted a retrospective study to describe the role of on-call neurologists at Hospital General Universitario Gregorio Marañón, a tertiary care centre in Madrid, Spain. Sociodemographic characteristics, most common pathologies, diagnostic tests, and destination of the patients attended were recorded daily using a computer database. Results were compared with the general care data from the emergency department. RESULTS: The team attended 3234 patients (3.48% of the emergency department total). The mean number of patients seen per day was 11.15. The most frequent pathologies were stroke (34%), epilepsy (16%) and headache (8%). The mean stay in the emergency department was 7.17 hours. Hospital admission rate was 40% (7.38% of emergency hospital admissions). The main destinations for admitted patients were the stroke unit (39.5%) and the neurology department (33%). Endovascular or thrombolytic therapies were performed on 76 occasions. Doctors attended 70% of the patients during on-call hours. CONCLUSIONS: Emergency neurological care is varied, complex, and frequently necessary. Neurological cases account for a sizeable percentage of both patient visits to the emergency room and the total number of emergency admissions. The current data confirm that on-call neurologists available on a 24-hour basis are needed in emergency departments.

El empleo de un formulario estructurado mejora la calidad de la historia clínica de urgencias de pacientes con ictus agudos / The use of a pro-forma improves the quality of the emergency medical charts of patients with acute stroke

Introducción: La información obtenida mediante la historia clínica de urgencias (HCU) resulta determinante para el correcto manejo del paciente con ictus agudo. Pretendemos determinar si el empleo de un formulario estructurado (FE) para la elaboración de la HCU mejora la calidad de la información clínica.Material y métodos: Elaboramos un listado de 26 variables que consideramos importantes en el manejo del ictus agudo. Comparamos el número de variables recogidas en las HCU de pacientes ingresados en la unidad de ictus (UI) en enero-febrero 2009, antes de la implantación del FE (FE–), con los datos recogidos con el FE (FE+) (abril-mayo de 2009). Asimismo, analizamos la coincidencia con el diagnóstico definitivo al alta de la UI.Resultados: Analizamos 128 HCU, 80 FE–, 48 FE+. En las FE+, se recogió una media de 20,5 variables frente a 13,7 en las FE– (p<0,001); 16 variables se recogieron con frecuencia significativamente mayor (p<0,05) en las historias con FE+. Entre ellas destacaron: vida basal (100% vs 51%), escala Rankin previo al ictus (94% vs 1%), fecha y hora de inicio del ictus (100% vs 85%), fecha y hora de atención neurológica (100% vs 39%), NIHSS (92% vs 30%), resultado ECG (88% vs 59%), fecha y hora de realización de TC craneal (60% vs 1%). Coincidencia diagnóstica: diagnóstico nosológico/sindrómico: FE+: 94%, FE–: 60% (p<0,001), diagnóstico topográfico: FE+: 71%, FE–: 53% (p=0,03), diagnóstico etiológico: FE+: 25%, FE–: 9% (p=0,01).Conclusiones: El empleo de un FE permite mejorar cuantitativa y cualitativamente la información recogida en la HCU y aporta una mayor precisión diagnóstica

Introduction: The information obtained from the Emergency Medical Chart (EMC) is a key factor for the correct management of acute stroke. Our aim is to determine if the use of a pro-forma (PF) for filling in the EMC improves the quality of the clinical information. Material and methods:A PF was created from a list of 26 key-items considered important to be recorded in an EMC. We compared the number of items recorded in the EMC of patients admitted to our Stroke Unit (SU) in January-February 2009 (before PF was introduced) with the data obtained with the PF (April-May, 2009). We also analysed the agreement with the final diagnosis on discharge from the SU. Results:A total of 128 EMC were analysed, and the PF was used in 48 cases. The mean number of recorded items was 20.5 for the PF group and 13.7 for the non-PF charts (P<.001). Sixteen of the 26 items were recorded significant more frequently (P<.05) in the PF Group. The most notable scores being: previous baseline situation (100% vs 51%), previous Modified Rankin scale score (94% vs 1%), time of symptom onset (100% vs 85%), time of neurological evaluation (100% vs 39%), NIHSS score (92% vs 30%), ECG results (88% vs 59%), time of perform brain scan (60% vs 1%). Diagnostic agreement: nosological/syndromic diagnosis: PF group: 94%, Non-PF group: 60% (P<.001), topographic diagnosis: PF: 71%, Non-PF: 53% (P=.03), aetiological diagnosis: PF: 25%, Non-PF: 9% (P=.01).Conclusions: The use of a PF improves the quantity and quality of the information, and offers a better diagnostic accuracy

[The use of a pro-forma improves the quality of the emergency medical charts of patients with acute stroke]. / El empleo de un formulario estructurado mejora la calidad de la historia clínica de urgencias de pacientes con ictus agudos.

INTRODUCTION: The information obtained from the Emergency Medical Chart (EMC) is a key factor for the correct management of acute stroke. Our aim is to determine if the use of a pro-forma (PF) for filling in the EMC improves the quality of the clinical information. MATERIAL AND METHODS: A PF was created from a list of 26 key-items considered important to be recorded in an EMC. We compared the number of items recorded in the EMC of patients admitted to our Stroke Unit (SU) in January-February 2009 (before PF was introduced) with the data obtained with the PF (April-May, 2009). We also analysed the agreement with the final diagnosis on discharge from the SU. RESULTS: A total of 128 EMC were analysed, and the PF was used in 48 cases. The mean number of recorded items was 20.5 for the PF group and 13.7 for the non-PF charts (P<.001). Sixteen of the 26 items were recorded significant more frequently (P<.05) in the PF Group. The most notable scores being: previous baseline situation (100% vs. 51%), previous Modified Rankin scale score (94% vs. 1%), time of symptom onset (100% vs. 85%), time of neurological evaluation (100% vs. 39%), NIHSS score (92% vs. 30%), ECG results (88% vs. 59%), time of perform brain scan (60% vs. 1%). Diagnostic agreement: nosological/syndromic diagnosis: PF group: 94%, Non-PF group: 60% (P<.001), topographic diagnosis: PF: 71%, Non-PF: 53% (P=.03), aetiological diagnosis: PF: 25%, Non-PF: 9% (P=.01). CONCLUSIONS: The use of a PF improves the quantity and quality of the information, and offers a better diagnostic accuracy.