Risk assessment for Venous ThromboEmbolism (VTE)

Venous thrombosis is a potentially life-threatening, but reversible pathological process. It can progress to thromboembolism, usually producing a pulmonary embolism. The risk of VTE is higher amongst certain patients, but the risk can be modified with pharmacological.

All patients should be risk assessed on admission to hospital. Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes.

Patients who may require intervention include:

• All surgical patients
• Medical patients expected to have ongoing reduced mobility relative to normal state.

 

Factors which increase risk of thrombosis (may indicate anticoagulation)

• Active cancer or cancer treatment 
• Age > 60
• Dehydration
• Known thrombophilias
• Obesity (BMI > 30 kg/m2)
• Significant medical comorbidities
• Personal history or first-degree relative with a history of VTE
• Use of hormone replacement therapy
• Use of oestrogen-containing contraceptive therapy
• Varicose veins with phlebitis
• Pregnancy or < 6 weeks post-partum
• Significantly reduced mobility for 3 days or more
• Hip or knee replacement
• Hip fracture
• Total anaesthetic + surgical time > 90 minutes
• Surgery involving pelvis or lower limb with a total anaesthetic + surgical time > 60 minutes
• Acute surgical admission with inflammatory or intra-abdominal condition
• Critical care admission
• Surgery with significant reduction in mobility

 

Factors which increase bleeding risk (may contraindicate anticoagulation)

• Active bleeding
• Acquired bleeding disorders (such as acute liver failure)
• Concurrent use of anticoagulants known to increase the bleeding risk
• Acute stroke
• Thrombocytopoenia
• Uncontrolled systolic hypertension
• Untreated inherited bleeding disorders
• Neurosurgery, spinal surgery, or eye surgery
• Other procedure with high bleeding risk
• Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours
• Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours

 

Example of an assessment form

References

1. National Institute for Health and Clinical Excellence (2010) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE clinical guideline 92. London: National Institute for Health and Clinical Excellence.

Conjunctivitis

Disease class: Conjunctival diseases

Miliaria

Disease class: Sweat gland diseases

Also known as

• Sweat rash
• Heat rash
• Prickly heat

Pathophysiology

When sweating is initiated, the sweat must be able to drain from the ducts. If they are blocked, milaria results.
Children have less highly developed sweat ducts, so the disease is more likely to occur in young children.

 

Management

Initially, medical assistance should not be sought.

Hordeolum

Disease class: Eyelid diseases

Also known as

• Stye (if on the external eyelid)
• Hordeola (plural)

This refers to an acute infection of either the glands of Zeis (external eyelid) or the meibomian glands (internal eyelid). 

 

Causes

• Staphyloccocal infection

Tinea

Disease class: Dermatomycosis

Also known as

• Dermatophytosis
• Ringworm
  

 

Subtypes

• Tinea capitis (of the head)
• Tinea corporis (of the body)
• Tinea cruris (of the leg), jock itch
• Tinea pedis (of the foot), athlete's foot

 

Tinea refers to a fungal infection of the skin.

This is a very common condition.

Causes

~40 species of fungus

• Trichophyton rubrum (most common)
• Various others 

 

Symptoms

• Itch
  

 

Signs

• Rash
• Erythema
• Scaled
• Circular (ring-shaped)
  

Common cold

Disease class: Respiratory tract infections

Also known as

• Acute coryza 

 

Symptoms

• Catarrh
• Rhinorrhoea
• Malaise
  
• Fatigue
  
• Cough
  
• Fever
• Muscle aches
  

 

Causes

• Over 200 known viral strains 
• Coronaviruses
  
• Rhinoviruses
  

Water-electrolyte imbalance

Disease class: Metabolic diseases

Types

• Dehydration 
• Hypercalcaemia 
• Hyperkalaemia 
• Hypernatraemia 
• Hypocalcaemia 
• Hypokalaemia 
• Hyponatraemia 
• Inappropriate ADH syndrome 
• Water intoxication

Hiccups

Also called hiccoughs.

 

Physiology

A hiccup is a very a common and harmless phenomenon. 

It is a reflex arc from the diaphragm, up the phrenic nerve to the brainstem, then down the vagus nerve to the muscle fibers. It causes involuntary contraction of the diaphragm. The characteristic "hic" or "hup" sounds are caused by an involuntary closure of the glottis as air is drawn past them by the contracting diaphragm. The process usually repeats and may last for minutes or even days. 

The causes and treatments of hiccups are so numerous, that there is no consensus on how exactly the process is coordinated in the brain. The initiation and termination of hiccups are likely mediated by various neurotransmitters.

There is a phylogenetic hypothesis that hiccups are a remnant from the evolutionary history of humans. It may be an earlier pathway of respiration which was used by amphibious ancestors. 

 

Pathology

Even a prolonged bout of hiccups is usually not a sign of underlying disease. 

Hiccups can be triggered by: 

• Excessive air swallowing
• Eating too rapidly
• Intense emotions
• Laughter
• Certain beverages and foods

However, in some cases, it is a useful diagnostic clue. 

• Abdominal pathologies. E.g. subphrenic abscess. In cases with an abdominal infection, the diaphragm can become irritated, stimulating the phrenic nerve. 
• Metabolic disorders. E.g. uraemia. Uraemia may stimulate the initiation of hiccuping in the medulla. 
• Lesions of the central nervous system. E.g. brainstem tumours. 
• Lesions of the vagus nerve. 
• Psychogenic disorders. 
• Drug use. E.g. opioids.  

 

Management

Simple hiccups can often be resolved by simple stimulation of the involved nerves. For example, holding your breath, swallowing water, and other maneuvers may stimulate the glottis.