Thursday, 25 October 2007

Dr Makoto Aoki-- What a Great Guy !!

Dr Makoto Aoki visited out institution to answer to a case on meningitis. He went through the various types of meningitis and stressed the importance of taking a sexual history.

He reminded us about 'aseptic meningitis' such as vasculitis (SLE, Behcet), malignancy (metastases), drugs (NSAIDs), Infective ( viral: HIV, mumps, enterovirus, herpes simplex virus; bacteria: partially treated meningitis, TB, syphilis; fungal: cryptococcus, candida ). Moreover, bystander meningitis e.g.caused by a paravertebral abscess is another important cause.

He also reminded the doctors that being married does not exclude patients from engaging in sex with the same or opposite sex and hence, sexually transmitted infections are an important cause of meningitis. Hence, a sexual history is an extremely important part of the work up of infectious diseases.

The turn out of doctors at the tutorial session was great ! The doctors were able to answer Dr Aoki’s difficult questions intelligently and more importantly, correctly !!

Dr Aoki’s sessions are always great fun and he tells some good jokes as well. These sessions provide a valuable time for the residents to learn new things and to relax from the busy daily schedule.

I for one am looking forwards to his next visit here in December.

Wednesday, 24 October 2007

The Funny Things in Medicine That Turn Out to be Sad

In my time I have experienced many funny situations in my medical life.

I write this blog today because of a situation I saw just recently when I was walking in the street. I saw a female walking from one side of the road to the other wearing normal clothes and seemingly doing what a normal person would do. She made her way to the cigarette machine in the street and was looking for small change to buy the cigarettes. In the night time when this occurred, I saw something dangling from her arm which was shinning in the light from the oncoming cars headlamps. I thought that my eyes were deceiving me until I got a better look and I realised it was a drip tube. Suddenly, the patient picked up her drip bag of intravenous fluid she was having at the time. Yes, the patient was so unwell requiring intravenous fluid that she was able to get up and go out of the hospital to buy some cigarettes.

It also reminded me of when I was a first year doctor in London when I was treating a drug addict with cellulitis and anaemia. He required intravenous antibiotics and blood transfusions. However, the only available venous access was a small superficial vein in his neck to which the blood transfusion was attached. He soon went missing from the ward and despite searching for him, he had left the hospital with his blood transfusion still running!! On my way out of the hospital in the evening sunset, I saw the patient begging on the road trying to sell his blood transfusion to oncoming Londoners, no doubt so he could buy more drugs and use the intravenous access made for medical purposes as his no inlet for illicit drugs.... This was a desperate man who needed help and it showed to me just how far some people will go to try and maintain a drug habit.

At the same hospital, I was on-call one night when a patient was admitted with chest pain from a possible crises from sickle cell diseases. She was screaming for pethidine, a fast acting synthetic opioid drug that can be highly addictive. She was not from the local area and so after checking with several other hospitals to which she had been admitted with the same problem it became clear that she always asked for pethidine. At one point she grabbed hold of my arm and screamed at me to give her pethidine. I offered her other pain relief such as oral morphine as a substitute but she refused it. The reason is, oral morphine is good for pain relief but does not give a sudden "hit" that one gets from pethidine or heroin (diacetylmorphine). Hence, it became clear that the patient was after a fix of pethidine because of the unfortunate addiction that can occur from the treatment of sickle cell crises.... I felt sorry for the lady but she soon discharged herself from the ER department as she had failed to obtain the fast acting opioid she had been after.

Another example, was a man I saw when I was a medical student. He was admitted with severe pain in his loin radiating to his groin. He was writhing around in pain on the bed and was shouting for pain relief. His thermometer registered a fever and analysis of his blood revealed lots of blood. For all intents and purposes, any competent doctor would immediately investigate and treat as a renal stone plus infection. Renal stones can be very painful and sometimes NSAIDs do not take the pain away. In the end, he was given Entonox (nitrous oxide) that is also used more commonly during childbirth. He went through almost 2 large bottles of the stuff before the ER doctor decided to investigate things further.... After ringing other hospitals it soon became clear that the patient was a 'hospital hopper' and had been discharged from several other institutions with the identical same symptoms and was easily identifiable because of a unique tattoo on his arm. After being confronted, he got up as if nothing had happened and walked out the ER having succeeded in obtaining Entonox !
He had put the thermometer up to the light bulb in his cubicle to give him a fever and had pricked his finger to put blood in his urine. I had been completely had almost all of the ER staff !!

Lastly, but by no means least, when I was a junior doctor on-call in ER, I saw an ER senior doctor seeing to a young man having seizures. However, the patient's type of the seizures was unusual as he did not have any prolonged confusion or tiredness i.e. no post-ictal state. Moreover, there was no tongue biting and no incontinence. The patient failed the drop test which involved dropping the patients arm onto his face. If the arm hits the face, the patient is unconscious, but if the patient is faking unconsciousness, unless they know about the test, they usually avoid hitting themselves! Following this, the ER doctor was suspicious of pseudoseizures and the purpose of the patient doing this was to obtain free IV benzodiazepine-- the treatment for seizures but also an addictive drug!!!

A consultant then saw the patient at which point he said the following-- 'we take the testicle and strike it hard with the tendon hammer. If the patient is truly unconscious he will not feel pain, but if he is faking it....' He then walked away from the patient pretending to go and find the tendon hammer. Within 1 minute the patient had jumped off the ER bed, now fully conscious, and shouted a few obscene words at the consultant and ER staff before running out of the hospital.....

I hope that you have enjoyed these few examples of unusual patients. Although such cases may seem humorous initially, each case described above involves an addiction of some sort which made these patients do something that is an unacceptable thing in normal society. Whether it be going to buy cigarettes wearing a drip or selling blood transfusions, such unusual actions show us as doctors that there are many people out there in the world with problems related to addiction to chemicals or drugs. How can we help such people?

Do you have any good examples of real cases you would like to share???? Please send your comments to my blog for us all to share.

Tuesday, 23 October 2007

CT and Function

Although the use of CT scanning and MRI have transformed the world of doctoring for rapid diagnosis of conditions such as stroke and cancer, they do nothing to tell us how the patient is functioning.

As has been my experience in Japan, when a patient comes into hospital with some disorder that may indicate a cerebral problem, they are whisked into the waiting CT scanner for thieir cranial scan with or without contrast. Sometimes the neurological examination is bypassed as it is the belief that the scanner can give the answer to the problem.

To some extent, the use of scanning can give the answer, although not in its entirety.

A CT scan provides only pictures. Patients and their families are not interested in pictures that they bearly understand. They are interested on how the problem is going to affect them, for example, how it will affect their function.

The only way the function of a patient can be assessed is through examination.

Neurological examination is an indirect method of trying to understand what is going on in the head, spinal cord and muscles. It cannot tell us exactly what is going on, but it can tell us where a potential lesion exists and how it is affecting the function of the patient.

In fact, the use of physical examination of the neurological system and CT or MRI scanning complement eachother. However, a normal physical examination often does not require us to obtain a CT scan and a normal CT scan does not exclude an abnormality of function on examination.

Hence, physical examination is still a very much important part of a physicians armoury and it should not be skipped in favour of scanning the patient because important things can and will be missed.

For example, a patient admitted with sudden onset of speech abnormality and vomiting was found to have metastases on chest xray and hence, cerebral mets were suspected. CT was performed which indeed confirmed the mets. Great diagnosis......but the missing component was the functional ability of the patient.

When he was later examined by another doctor it was found that the patient had developed an homonymous hemianopia and unilateral upper limb weakness in addition to the speech abnormality. These differing neurological features suggest multiple areas affected. Moreover, such an examination revealed that the patient would be unsafe to drive (if feasible) because of the loss of vision and weakness of an upper limb. Following this, when one reviewed the physical findings to the CT result, it then made understanding the CT more easy as it could be understood that the patient's optic radiations to the occipital lobe had been disrupted by metastases and the speech abnormality was due to a pre-frontal lobe metastatic haemorrhage disrupting the pre-motor area in additon to the mutiple cerebellar lesions.

Acute treatment consisted of commencing dexamthasone to reduce the oedema. However, if no initial assessment of function through physical examination had been done, then there would be no way to fully know if the patient was improving or not. There needs to be a baseline admission examination.

In the UK, obtaining an emergency CT without the agreement of a radiologist is difficult. All emergency requests must be shown to the radiologist and for the decision to then be made by him or her. In my own experience, on occasions, radiologists have asked about the neurological examination and what you expect to find. If there is no physical examination or a poor physical examination performed, they will reject the request until an acceptable examination has been performed. Yes, you may think this is strict and overly controlling and to some extent it is, but it does ensure that the doctors examine their patient, think of the potential causes and what they will do if they find what they are looking for. It also reduces the unnecessary number of requests for head CT scans from anxious patients that think they have a brain tumour.

Unless a full neurological examination is performed with fundoscopy, the CT request may find itself coming back to you as rejected !! Obviously, this is case by case.

Hence, in the UK, physical examination is the mainstay of making diagnoses and in circumstances when a CT or MRI scan is needed, it will get done. In those cases where there is no clear reason for a CT but the patient wants it or the doctor wants reassurance, it is likely to be rejected by the radiologist. This cuts done on expenditure and unnecessary scanning.

The take home message is, always examine your patients neurology when such an examination is warranted and try and consider the places in the CNS or PNS which have been affected and where such problems localise to. This will then give you some idea of where you are expecting to find the problems when you eventually do scan the patient. The examination will provide you with the baseline functional status and with serial examination of the patient, it will tell you whether the patient is improving or not.

Basically, don't think that a scan is the replacement for clinical skill because it is not.