Acute Medical Admissions Research Articles

The selection of acute medical admissions for a short-stay unit

Objective of this study is to evaluate the selection of patients to be admitted to a hospital medical short-stay unit (SSU) where acute medical admissions with a predicted length of stay of between 24 and 72h are managed. This is a retrospective observational study evaluating outcomes of all admissions to the medical SSU between January 2005 and December 2008. Factors that influence inappropriate allocation of patients to the SSU or alternative longer stay medical units were evaluated. Length of stay (LOS), mortality, Charlson score, admission to intensive care unit (ICU) (from the SSU), discharge diagnosis, and 7-day readmission rate were analysed. Over 4years, 45% of the general medical inpatient take, 9,125 admission episodes, were managed by the medical SSU. On an average, 72% of these admissions to the SSU stayed fewer than 72h. After excluding in-hospital deaths, there were 8,381 admissions to the general medical unit discharged within 72h, and 77% of these were managed by the SSU during the study period. Inappropriate admissions to the SSU (LOS more than 72h) tended to be older patients with more complex medical comorbidities. Other factors contributing to prolonged stay in the SSU included weekend admissions, and transfers to the ICU. The 7-day readmission rate was low at 3%; the all-cause hospital mortality for patients admitted to the medical SSU was 2% despite a 32% increase in workload in the medical SSU over these 4years. In the context of fixed resources and a steeply increasing patient workload, a large proportion of general medical patients can be managed in a medical SSU with the majority being discharged home within 72h while keeping all-cause in-hospital mortality and readmission rates low. More accurate identification of appropriate patients on admission by using a physiological clinical score and addressing operational issues particularly on weekends could lead to a more efficient SSU.

Exploratory study of the ‘weekend effect’ for acute medical admissions to public hospitals in Queensland, Australia

To determine whether in-hospital deaths of patients admitted through emergency departments with acute exacerbations of chronic obstructive pulmonary disease (COPD), acute myocardial infarction, intracerebral haemorrhage and acute hip fracture are increased by weekend versus weekday admission (the 'weekend effect'). We performed a retrospective analysis of statewide administrative data from public hospitals in Queensland, Australia, during the 2002/2003-2006/2007 financial years. The primary outcome was 30-day in-hospital mortality. The secondary outcome of 2-day in-hospital mortality helped determine whether increased mortality of weekend admissions was closely linked to weekend medical care. During the study period, there were 30 522 COPD, 17 910 acute myocardial infarction, 4183 acute hip fracture and 1781 intracerebral haemorrhage admissions. There was no significant weekend effect on 30-day in-hospital mortality for COPD (adjusted risk ratio = 0.92, 95% CI: 0.81-1.04, P= 0.222), intracerebral haemorrhage (adjusted risk ratio = 1.01, 95% CI: 0.86-1.16, P= 0.935) or acute hip fracture (adjusted risk ratio = 0.78, 95% CI: 0.54-1.03, P= 0.13). There was a significant weekend effect for acute myocardial infarction (adjusted risk ratio = 1.15, 95% CI: 1.03-1.26, P= 0.007). Two-day in-hospital mortality showed similar results. This is the first Australian study on the 'weekend effect' (in a cohort other than neonates), and the first study worldwide to assess specifically the weekend effect among COPD patients. Observed patterns were consistent with overseas research. There was a significant weekend effect for myocardial infarction. Further research is needed to determine whether location (e.g. rural), clinical (e.g. disease severity) and service provision factors (e.g. access to invasive procedures) influence the weekend effect for acute medical conditions in Australia.

Pharmacy services at admission and discharge in adult, acute, public hospitals in Ireland

to describe hospital pharmacy involvement in medication management in Ireland, both generally and at points of transfer of care, and to gain a broad perspective of the hospital pharmacy workforce. a survey of all adult, acute, public hospitals with an accident and emergency (A&E) department (n = 36), using a semi-structured telephone interview. there was a 97% (n = 35) response rate. The majority (n = 25, 71.4%) of hospitals reported delivery of a clinical pharmacy service. On admission, pharmacists were involved in taking or verifying medication histories in a minority (n = 15, 42.9%) of hospitals, while few (n = 6,17.1%) deployed staff to the A&E/acute medical admissions unit. On discharge, the majority (n = 30,85.7%) did not supply any take-out medication, a minority (n =5,14.3%) checked the discharge prescription, 51.4% (n = 18) counselled patients, 42.9% (n = 15) provided medication compliance charts and one hospital (2.9%) communicated with the patient's community pharmacy. The number of staff employed in the pharmacy department in each hospital was not proportionate to the number of inpatient beds, nor the volume of admissions from A&E. There were differences identified in service delivery between hospitals of different type: urban hospitals with a high volume of admissions from A&E were more likely to deliver clinical pharmacy. the frequency and consistency of delivering pharmacy services to facilitate medication reconciliation at admission and discharge could be improved. Workforce constraints may inhibit service expansion. Development of national standards of practice may help to eliminate variation between hospitals and support service development.

Comparison of Endoscopically Evaluated Etiologies of Upper GI Bleeding of Adult Sri Lankans with International Studies Admitted to a Medical Unit of a Tertiary Care Center

Purpose: To compare etiology of upper GI bleeding affecting adult Sri Lankans, with results of international studies, admitted to a medical unit of a tertiary care center. Methods: Case notes of 1500 patients who had undergone upper GI endoscopy for varices from 13.3.2002 to 13.2.2004 were retrospectively analyzed and those who had clinical evidence of upper GI bleeding were selected.Table: [1394]Results: A total of 345 patients had upper GI bleeding with a male:female ratio of 229:114 (2:1). The majority was in the 51-70 age range. Endoscopy showed presence of severe antral gastritis with duodenitis, esophagitis, peptic ulcer disease, esophageal varices, pangastritis, erosions and malignancies in 48%, 28%, 28%, 32%, 15%, 17% and 5% of the instances, respectively. Vast majority showed overlapping pathologies. Only about 50% of the varices showed evidence of bleeding. 12% showed negative endoscopies. 10% were on NSAIDS and 9% were alcohol abusers. The table below depicts a comparison of above etiologies with several international studies. Table 01 is a comparison of causes of UGIB of other published studies with the current data. Conclusion: Upper GI bleeds are a major cause of acute medical admissions in Sri Lanka constituting about 25% of the endoscopy work. Amongst aetiological lesions of upper GI bleeding, AGML, osophagitis, and varices had been the major pathologies in this part of the world, in contrast to the West. NSAIDs and alcohol had been important associated contributory factors and there was a clear male preponderance in the bleeders. National and regional guidelines should be formulated based on these observations to educate general public of the contributory factors, mainly alcohol and NSAIDs.

Age and outcome in acute emergency medical admissions

there is a lack of outcome information with respect to older health service users. The purpose of this study was to examine 30-day in-hospital mortality and its predictors in all elderly patients admitted as a medical emergency to our hospital. all patients admitted between 2002 and 2008 were studied, linking anonymised clinical, administrative, laboratory and mortality data. Significant univariate predictors of outcome, including co-morbidity and illness severity score, were entered into a multivariate logistic regression model, adjusting the univariate estimates of the effect of age on in-hospital mortality. we admitted 23,114 consecutive acute medical admissions between 2002 and 2008; 30-day in-hospital mortality was 20.7% in the over 75 age category versus 4.5% in those younger. The unadjusted OR for a 30-day in-hospital mortality in the over 75 category of 5.21 (95% CI 4.73, 5.73) fell to 4.69 (95% CI 4.04, 5.44) when adjusted for outcome predictors excluding acute illness severity and 2.93 (95% CI 2.50, 3.42) when acute illness severity was added as a covariate. When the interaction between age and co-morbidity is examined, the odds ratio adjusts to 3.22 (95% CI 2.63, 3.6). acute illness severity is more important than co-morbidity in explaining the outcome in older patients admitted as medical emergencies. Service planning for acute elderly care should be based on effective disease management programmes but recognise the contribution of acute illness severity to outcome when conditions deteriorate.

Mortality following acute medical admission in Denmark: a feasibility study

BackgroundAs the population ages, an increasing number of acute medical patients will be older and have comorbidities that may interact with their primary admission condition and worsen their prognosis.ObjectivesTo examine whether 6-month mortality following acute medical admission was associated with gender, age, or comorbidity.MethodsWe used the Danish National Patient Registry, covering all Danish hospitals, to identify all acute medical admissions to Aarhus University Hospital during 2008 and comorbidities. We obtained mortality data from the Danish Civil Registration System. We computed mortality risks and hazard ratios with 95% confidence intervals (CIs) for gender, age, and comorbidity groups.ResultsWe identified 3,727 patients (53.6% women) with a median age of 63 years for women and 60 years for men. The overall 6-month mortality rate was 12.8%. The adjusted hazard ratio was 2.77 (95% CI, 2.11–3.64) for patients aged 65–80 years and 5.25 (95% CI, 4.06–6.80) for patients older than 80 years, compared with patients younger than 65 years. The adjusted hazard ratio was 2.43 (95% CI, 1.82–3.24) and 3.87 (95% CI, 2.91–5.15) for patients with moderate and high comorbidity, respectively, compared with low comorbidity.ConclusionAge and comorbidity were important predictors of mortality after acute medical admission.

ViEWS—Towards a national early warning score for detecting adult inpatient deterioration

Aim of study To develop a validated, paper-based, aggregate weighted track and trigger system (AWTTS) that could serve as a template for a national early warning score (EWS) for the detection of patient deterioration. Materials and methods Using existing knowledge of the relationship between physiological data and adverse clinical outcomes, a thorough review of the literature surrounding EWS and physiology, and a previous detailed analysis of published EWSs, we developed a new paper-based EWS – VitalPAC™ EWS (ViEWS). We applied ViEWS to a large vital signs database ( n = 198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions, and also evaluated the comparative performance of 33 other AWTTSs, for a range of outcomes using the area under the receiver-operating characteristics (AUROC) curve. Results The AUROC (95% CI) for ViEWS using in-hospital mortality with 24 h of the observation set was 0.888 (0.880–0.895). The AUROCs (95% CI) for the 33 other AWTTSs tested using the same outcome ranged from 0.803 (0.792–0.815) to 0.850 (0.841–0.859). ViEWS performed better than the 33 other AWTTSs for all outcomes tested. Conclusions We have developed a simple AWTTS – ViEWS – designed for paper-based application and demonstrated that its performance for predicting mortality (within a range of timescales) is superior to all other published AWTTSs that we tested. We have also developed a tool to provide a relative measure of the number of “triggers” that would be generated at different values of EWS and permits the comparison of the workload generated by different AWTTSs.

Does Mixing Acute Medical Admissions with Burn Patients Increase Infective Complications from Paediatric Thermal Injuries?

In the winter of 2005–2006, the management at our children's hospital elected to admit ‘overspill’ acute medical admissions to the ward used for plastic surgery and burns for logistical reasons. This study was conducted to assess the effects of that change on the incidence of infective complications in thermally-injured patients. Seventy-three patients were studied, 23 in the sample winter and 50 in the two preceding control winters. The data gathered included days on IV fluids and antibiotics, transfer to the Paediatric Intensive Care Unit (PICU), microbiology and a ‘septic signs score’ – based on pyrexia, irritability, diarrhoea/vomiting, wound colonization, bacteraemia. The outcomes studied were: the maximum ‘septic signs score’; patients with a score ≥3; wound colonization; PICU admission; days on antibiotics and IV fluids. A statistically significant increase in patients with septic episodes was demonstrated by an increase in the mean septic signs score (0.66–1.48, P = 0.044) and the number of patients with a score ≥3 (4–22%, P = 0.017). Other analysed variables did not reach statistical significance although the raw data suggested a trend. It was concluded that there is an association between mixing acute medical admissions with thermally-injured patients and an increase in the incidence of infective complications in the latter group.

Assessing the need for hospital admission by the cape triage discriminator presentations and the simple clinical score

AimThere is uncertainty about how to assess unselected acutely ill medical patients at the time of their admission to hospital. This study examined the use of the Simple Clinical Score...

The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration

To assess the impact of a set of interventions in reducing the interruption/distraction rate during medication administration. Pre- and postintervention observational study of nurses undertaking medication rounds. Acute Medical Admissions Unit (AMAU) of a 1000-bed teaching hospital. A set of measures previously proven successful in reducing interruptions (behaviour modification and staff education; checklists; visible symbols in the form of a red vest; and signage) were adapted and introduced onto the AMAU. Rate of interruptions and distractions pre- and postintervention overall and for each individual source of interruption. There was a highly significant association (p<0.0001) between the overall interruption/distraction rate and the pre-/postintervention studies, with the rate of interruptions postintervention being 0.43 times that of the preintervention level. When individual sources of interruptions and distractions were compared pre- and postintervention, a significant difference (p<0.05) in the interruption/distraction rate was found for five of the 11 categories assessed. The data support a multifactorial approach to reducing the interruption/distraction rate on medication rounds. Suggestions for future research include: directly quantifying the impact of the interventions described in this study on the volume of medication administration errors; assessing the time lost as a result of interruptions and distractions during the medication round; and developing a standardised means of recording and analysing interruptions and distractions to allow meaningful comparison of the benefits of interventions across studies.

Can a random serum cortisol reduce the need for short synacthen tests in acute medical admissions?

Short synacthen tests (SSTs) are frequently performed in medical inpatients with suspected adrenocortical insufficiency. The utility of a random or baseline serum cortisol in this setting is unclear. We determined random cortisol thresholds that safely preclude SSTs in acute medical admissions. We analysed SSTs in acute non-critically ill general medical patients (n = 166, median age 66, range 15-94 y; men 48%, women 52%). The SST was defined according to the 30-min cortisol as 'pass' (>550 nmol/L) or 'fail' (< or =550 nmol/L). Receiver operating characteristics (ROC) curves were generated to determine the predictive value of the basal cortisol for a failed SST. Of 166 SSTs, a pass was seen in 127 (76.5%) tests, while 39 (23.5%) tests failed the SST. ROC curves showed that no single cut-off point of the baseline cortisol was adequately both sensitive and specific for failing the SST despite a good overall predictive value (area under curve 0.94; 95% confidence interval 0.89-0.98). A basal cortisol <420 nmol/L had 100% sensitivity and 54% specificity for failing the SST, while a basal cortisol <142 nmol/L had 100% specificity and 35% sensitivity. Restricting the SST to patients with a basal cortisol <420 nmol/L would have prevented 44% of SSTs while correctly identifying all patients who failed the SST. A baseline serum cortisol may prevent unnecessary SSTs in medical inpatients with suspected adrenocortical insufficiency. However, SSTs are still indicated in patients with random cortisol <420 nmol/L, or where the suspicion of adrenal insufficiency is compelling.

Use of intensive care, mechanical ventilation, both, or neither by patients with acute lung injury

Reports of acute lung injury and acute respiratory distress syndrome have generally been restricted to mechanically ventilated intensive care unit patients, creating an incomplete picture of the epidemiologies of the syndromes. We sought to determine the incidence and outcomes of acute lung injury and acute respiratory distress syndromes throughout an entire hospital population. Retrospective cohort study. A Department of Veterans Affairs medical center. All patients satisfying criteria for acute lung injury or acute respiratory distress syndrome during a 2-yr period. None. There were 11,465 acute medical and surgical admissions during the study period; 156 patients had acute lung injury or acute respiratory distress syndrome. Only 74 (47%) were invasively ventilated in an intensive care unit for acute lung injury. Another 15 (10%) patients were ventilated for other reasons, 41 (26%) were admitted to an intensive care unit at approximately the time of acute lung injury onset but were not invasively ventilated, and 26 (17%) were managed with neither invasive ventilation nor admission to an intensive care unit. Four-week mortality differed by group (p = .023), ranging from 22% among those managed in an intensive care unit without invasive ventilation to 50% among those ventilated for acute lung injury or acute respiratory distress syndrome. By 2 yrs, differences in survival between groups were no longer significant. Notably, only 53 (34%) patients would have been eligible for widely cited acute lung injury intervention trials. Ten patients had a second episode of acute lung injury during the study period, equating to a 16%-per-year risk of recurrence. Acute lung injury and acute respiratory distress syndrome studies restricted to patients mechanically ventilated in intensive care units substantially underestimate the incidence of the syndromes. Nonventilated patients and those cared for outside of intensive care units may still be at substantial risk for death. Further characterization of previously overlooked acute lung injury and acute respiratory distress syndrome patients may suggest new therapeutic opportunities.

Neurology on the acute take

Approximately 20% of acute medical admissions have a significant neurological problem.[1][1] One aim of the Association of British Neurologists (ABN) is that all these patients should be seen by a neurologist within 24 hours. This would require an increase in the number of dedicated neurology beds

Documentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache

Measuring cerebrospinal fluid (CSF) opening pressure by lumbar puncture (LP) is an essential tool in the investigation of patients with acute headache. To assess documentation of opening CSF pressure in those with acute headache undergoing LP. General documentation of the procedure and CSF investigations was also assessed. Retrospective review of medical records of patients admitted to a teaching hospital Acute Medical Admissions Unit over a three-month period with a presenting complaint of headache. A total of 106 patients presented with headache of whom 48 patients had at least one LP attempted. Only 41 patients (85%, 95% CI 72-94) had their LP documented. Of 47 patients that had a successful LP, 22 (47%) had a recorded opening pressure. Eighteen (32%) of all patients had their position recorded, with seven (15%) patients having had position and opening pressure documented. Twenty patients (43%) had the appropriate results documented. Twelve patients (31%) had paired serum glucose measured. Documentation of a LP for headache in the acute setting was generally poor. CSF opening pressure measurement was frequently omitted and no appropriate action taken if high. Paired serum glucose was rarely measured. Acute physicians may benefit from a proposed protocol and documentation sticker.

High prevalence of undiagnosed and severe chronic obstructive pulmonary disease at first hospital admission with acute exacerbation

Chronic obstructive pulmonary disease (COPD) is a common cause of acute medical hospital admission, and the prevalence of undiagnosed COPD in the community is high. The impact of undiagnosed COPD on presentation to secondary care services is not currently known. We therefore set out to characterise patients at first admission with an acute exacerbation of COPD, and to identify potential areas for improvement in earlier diagnosis and further management. A retrospective case review of patients first admitted to a district teaching hospital with an acute exacerbation of COPD over a 1-year period was carried out. Forty-one patients with a first admission with an acute exacerbation of COPD were identified, 14 (34%) of whom had not been previously diagnosed and were diagnosed with COPD as a result of the admission. At presentation, this group of patients had severe disease, with mean (SD) FEV(1) 1.02 (0.32) L, and a respiratory acidosis in eight (20%) patients, even though this was their first admission for an acute exacerbation of COPD. Missed potential opportunities to intervene in community and inpatient management were identified, including earlier diagnosis, pre-hospital corticosteroid therapy, inpatient respiratory team input, provision of smoking cessation advice and consideration of pulmonary rehabilitation. Patients with a first hospital admission with an acute exacerbation of COPD frequently have severe disease at presentation. Despite having severe disease, a diagnosis of COPD had not been made in the community prior to admission in one-third of patients. Future work should be directed at earlier identification of patients who are symptomatic from COPD and ensuring that the interventions of proven benefit in COPD are systematically offered to patients in both primary and secondary care.

The use of combined physiological parameters in the early recognition of the deteriorating acute medical patient

Early warning scores (EWS) are widely used to allow early recognition of the deteriorating patient. We aimed to test their ability to predict major deterioration in medical patients. Two cohorts were prospectively identified who were admitted to an acute medical admissions unit and to the respiratory unit but not admitted to the intensive care unit (ICU): medical-non ICU and respiratory-non ICU groups. Two further cohorts were retrospectively identified that required ICU admission from these units (medical-ICU and respiratory-ICU groups). Discriminant analysis and receiver operating characteristic curves were used to discriminate between groups, and time relationships were analysed. Heart rate (HR) and respiratory rate (RR) were significantly higher--and oxygen saturation (SaO₂) significantly lower--in the medical-ICU group as compared with the medical non-ICU group, and in the respiratory-ICU group as compared with [corrected] the respiratory-non ICU group. Discriminant functions incorporating HR, RR and SaO₂ performed at least as well as existing EWS systems in predicting ICU admission. Commonly used physiological parameters and existing EWS systems are useful at identifying sick patients. The discriminant functions described here appear to have a role in this setting but require validation in future studies.

Collaborative Audit of Risk Evaluation in Medical Emergency Treatment (CARE-MET I) — An international pilot

Background The absence of an accepted model for risk-adjustment of acute medical admissions leads to suboptimal clinical triage and serves as a disincentive to compare outcomes in different hospitals. The Simple Clinical Score (SCS) is a model based on 16 clinical parameters affecting hospital mortality. Methods We undertook a feasibility pilot in 21 hospitals in Europe and New Zealand each collecting data for 12 or more consecutive medical emergency admissions. Data from 281 patients was analysed. Results Severity of illness as estimated by SCS was related to risk of admission to the Intensive Care Unit ( p < 0.001) but not to the Coronary Care Unit. Mortality increased from 0% in the Very Low Risk group to 22% in the Very High Risk Group ( p < 0.0001). Very low scores were associated with earlier discharge as opposed to very high scores (mean length of stay of 2.4 days vs 5.6 days, p < 0.001). There were differences in the pattern of discharges in different hospitals with comparable SCS data. Clinicians reported no significant problems with the collection of data for the score in a number of different health care settings. Conclusion The SCS appears to be a feasible tool to assist clinical triage of medical emergency admissions. The ability to view the profile of the SCS for different clinical centres opens up the possibility of accurate comparison of outcomes across clinical centres without distortion by different regional standards of health care. This pilot study demonstrates that the adoption of the SCS is practical across an international range of hospitals.

Acute neurological problems: frequency, consultation patterns and the uses of a rapid access neurology clinic.

In secondary care, some patients with acute neurological symptoms are never seen by a neurologist. Rapid access neurology clinics could provide patients with timely access to neurology services. We analysed a retrospective cohort of 12,024 consecutive patients attending the 'immediate care' area of the emergency department or the acute medical admissions unit of the Royal Infirmary of Edinburgh. A total of 1,036 patients (9%) presented with a neurological complaint, of whom 680 (66%) did not have any contact with neurology services. The most common problems were epileptic seizure, cerebrovascular diseases and headache. Of the patients with epileptic seizure or headache who were not seen by a neurologist, about 40% might have benefited from neurological assessment. Following the introduction of a weekly rapid access neurology clinic, the most common problems seen were headache, symptoms that turned out to be medically unexplained and epileptic seizure.

A single-centre audit of junior doctors’ diagnostic activity in medical admissions

Practising doctors are distinguished from other healthcare staff by their role in making a clinical diagnosis. Huge changes in training and working practice in the past 15 years may have left many junior doctors ill equipped or preferring not to synthesise information to conclude a clerking with a diagnosis or differential diagnosis. This report details a retrospective study of acute medical admissions (AMU) first seen in the emergency department (A&E) and the diagnostic activity of junior doctors in both settings. The documented diagnostic conclusion and reported differential diagnosis was compared with that of the relevant admission consultant. The aim was to see if doctors completed their clinical assessment by establishing a 'reasonable differential diagnosis' or simply used the presenting complaint (a symptom) of the patient as the 'diagnosis'. One hundred patients' records (66 male and 34 female of mean age 57.4 years [20-94 years]) were studied. The majority of cases came from the cardiac and neurology domains of diagnosis. A total of 53% of cases seen in A&E by clinicians were given a clinical 'symptom' as a final diagnosis or differential diagnosis. A further 18% referred to the wrong clinical domain in their assessment, and 22% of cases were concordant with the eventual consultant diagnosis. In the AMU 20% of cases were given a symptom as a final diagnosis and 11% the wrong domain; 45% of diagnoses were concordant. The grade of the doctor, from foundation year (FY1) to specialty registrar (ST3), led to an expected improvement in the assessment and documentation of a possible diagnosis rather than a symptom for both A&E and AMU settings. In summary, junior doctors did not routinely document a clinical diagnosis or differential diagnosis at the conclusion of their clerking, regardless of experience. The reasons for this deferred activity are considered.

Acute dystonic reactions in a lady presenting with repetitive involuntary muscle twitching: a case report

A 56-year-old lady was admitted with complaint of involuntary muscle twitching around the eyes, face and neck for two days. She had a history of low grade non-hodgkin lymphoma with completion of the first cycle of chemotherapy. Her medication on presenting consisted of Ondansetron 8 mg two times a day and Metoclopramide 10 mg three times a day (TDS). She started taking these medications 24 hours before having the above symptoms. She was clinically diagnosed with acute dystonic reactions and was also secondarily treated with anti-emetic medications. She was given IV procyclidine 10 mg stat followed by per oral (PO) procyclidine 2.5 mg TDS. Within an hour of administering IV procyclidine her symptoms began to gradually settle down.Acute dystonic reactions are not a very rare clinical presentation in the daily practice. The above case is a good example for the clinicians dealing with acute medical admissions.