A Great Case of Twists and Turns

Dear Bloggers

This case is a great example of how to work up a Medical Patient and it shows how being too specialised in ones approach can cause the physician to lose sight of the bigger picture. This case wins by the fact that a senior doctor did not lose focus of all the medical problems and considered a unifying diagnosis under the principles of William of Okham, so-called Okham's Razor.

Case

An elderly gentleman was admitted into a hospital with a 6 month history of Gynaecomastia.

He had noticed breast enlargement and tenderness six months previously at which time it was noted that it was probably due to the spironolactone used for his heart failure and the drug was subsequently stopped. He had no galactorrhoea.

However, the gynaecomastia did not improve, so his local hospital measured the serum prolactin level which was found to be mildly raised (approximately 1.5 x normal) and he was sent to another hospital for more intensive investigation.

However, one week before admission to the next hospital, whilst walking, he developed sudden onset of lower back pain. The pain remained even at night and stopped him from sleeping. He was then having difficulty walking because of it.

On further questioning, Body Systems Review revealed a problem with urination as it took him some 5 minutes to void his urine. Moreover, he had no had an penile erection in 10 years. He had not lost any body hair although he had never had a lot in the past.

Body Systems Review also revealed no loss or change in vision and no headaches, nausea or vomiting.

Previous Medical History included ischaemic heart disease, heart failure, and COPD.

Drugs included furosemide, candesartan, beta-blocker and aspirin plus an H2-blocker.

He was an ex-smoker and drank 2 glasses of wine per day.

On examination, the patient was in severe pain and was lying still in bed but when moving, he screamed in pain.

General inspection showed mild gynaecomastia and loss of skin turgor plus dry skin. Temp 36.5, BP 124/78 (lying)

Cardiovascular examination revealed a pulse of 80 per minute and regular. JVP was raised to the angle of the jaw and showed a systolic 'v' wave consistent with Tricuspid Regurgitation. No murmur could be identified. No leg oedema was seen.

Respiratory examination showed a resp rate of 20/min, SpO2 of 95% on room air, central trachea, slightly hyper-inflated chest and normal vesicular breath sounds throughout the chest fields.

Abdominal examination revealed a slightly distended abdomen that was soft and non-tender with no abdominal masses. Bowel sounds were present. There were no hernial orifices and no AAA. Rectal examination had not been done !!! :-(

Neurological examination of the Lower Limbs was abnormal. Straight leg raising caused pain on the right leg at 70 degrees but immense pain of the left side at only 30 degrees-- a positive test.

The patient was unable to raise legs spontaneously due to pain. Reflexes showed hyper-reflexia throughout in upper and lower limbs but were absent at the ankles. Babinski sign was normal bilaterally. L5 dermatome on the left lower limb revealed loss of sensation (skin sensation below the knee).

CNS examination revealed normal cranial nerves throughout and there was no evidence of bitemporal hemianopia.

Examination of the lower spine was not painful to touch.

Lab data revealed a normal CBC, Normal Na & K but BUN was 50 and Creat 1.6.
Liver function was normal.
Calcium was 10.6 (mildly elevated)
Prolactin level was 1.5 times normal.
Thyroid function was normal
FSH/LH were 20-30 times normal and testosterone was low normal
Cortisol, GH and ACTH were normal.

CXR revealed a small area of scarring at the lateral right upper zone consistent with old TB but no evidence of malignancy.

Clinical Impression From History & Examination and Lab Data

Okay, this patient had in fact been admitted into hospital for a TRH stimulation test because of the raised prolactin. The back problem had not been known about until the patient had been admitted and had complained of the problem.

This patient therefore had several problems

• Gynaecomastia and Hyperprolactinaemia
• Renal Failure
• Hypercalcaemia (mild)
• Back pain of sudden onset with Lower Motor Neurone Signs.
• Probable Tricuspid Regurgitation
• High LH/FSH and low-normal testosterone (testicular failure)
  

In this case, I think the patient has developed gynaecomastia from hyperprolactinaemia and spironolactone. But, the drug was stopped. Prolactin can be raised for several reasons but most people immediately think Pituitary Tumour and do a reflex MRI head scan. Well, in view that the LH / FSH levels are high as well, one might naturally think it to be a pituitary source. However, pituitary adenomas in males present LATE and are usually macroadenomas (>10mm in size) and tend to cause Visual Disturbance. This patient had no obvious visual impairment.
The Raised LH and FSH should have caused a raised testosterone level, but they did not in this case because of the low-normal level (which is inappropriately low) thereby suggesting Testicular Failure.

In Testicular Failure, in response to low testosterone levels, the feedback loop of the pituitary axis is for LH and FSH to rise. Hence, the rise in these levels is unlikely to be due to a tumour. Moreover, LH-FSH secreting pituitary adenomas are rare. Also, prolactin when raised to very high levels e.g. 20x normal with prolactin secreting adenomas, there is inhibition of LHRH and reduction in LH & FSH; hence, in this case, with LH and FSH being high, it was unlikely to be caused by an adenoma. The fact that the other anterior pituitary hormones were left intact goes against panhypopituitarism.

History was important here because on Body System Review, it was elucidated that the patient had had no sexual activity in 10 years due to erectile failure, which again would fit with Testicular Failure. This patient did not offer the information of erectile failure spontaneously, but it was the clever junior doctor that asked the question and the patient then was able to answer to the affirmative.

The raised prolactin from a Prolactinoma, I would expect to be higher and as I say, I would expect some visual disturbance because of the nature of the presentation of pituitary adenomas in men.

However, one obvious cause of hyper-prolactinaemia is Hypothyroidism because of raised TRH in response to low T3/T4 also drives Prolactin release. In this case, all thyroid function was normal. Hence, it was not entirely clear why a TRH stimulation test was being performed at all. Some authorities advocate a TRH stimulation test, but it does not really tell you what or where the problem is. A TRH stimulation test is perhaps more useful when combined with a LHRH and insulin stress test for patients with suspected hypopituitarism, usually performed post-operatively for pituitary adenomas.

Perhaps, the most obvious cause of the Prolactin being elevated was renal failure induced by the Candesartan (ARB) plus furosemide [dry skin, reduced skin turgor].

There are numerous causes of hyperprolactinaemia which are detailed in any good textbook and are beyond the scope of today's talk.

Now, why did this patient get back pain?? Well, hypotestosteronaemia in men can result in osteoporosis. Referring back to the history, this patient was walking when he suddenly developed severe back pain. This suggests either a vertebral fracture or intervertebral disc herniation. One always has to considered serious causes of neurology such as cauda equina syndrome whereby the lower spinal nerves roots become compressed in a lower motor neurone distribution. Even worse is the conus medullaris syndrome with compression of the spinal cord that can lead to permanent paralysis of one or both lower limbs. In such conditions, patients can develop urinary problems such as retention and then overflow and hence, incontinence and the same can occur with the bowel giving constipation and then overflow diarrhoea.

That is why a rectal examination is so important !!! Rectal examination should always be done in patients with back pain and abnormal neurology affecting the lower limbs.

In this situation, it is useful to check TONE by asking the patient to squeeze with their anus on the examiners finger. Loss of tone is an ominous clinical sign. Moreover, checking sensation around the anus for numbness is also suggestive of a compression problem.

Rectal examination is also important in this case to identify possible prostate cancer as it might also account for the prolonged micturition symptoms and if metastatic, could result in a vertebral fracture.

Hence, a senior doctor who saw this patient suggested the possible diagnoses

1. Iatrogenic Renal failure with secondary Hyper-Prolactinaemia
2. Testicular Failure with Hypotestosteronaemia, raised LH and FSH
3. Osteoporotic fracture due to hypotestosteronaemia
4. Lower motor neurone signs of the left lower limb due to nerve impingement syndrome from likely intervertebral disc herniation
   

However, a pituitary adenoma would have needed to be ruled out by MRI head scan but in view of the previous insertion of coronary artery stents, the patient could not have such imaging. A CT head scan was not performed.

Results

Lumbar Xray did confirm a new vertebral disc fracture at the T12 position when compared to Xrays taken several months before and this 'biopsy' of the radiological archives indicated that he had been experiencing back pain for some time, although it had worsened on this admission due to the new fracture.
The ARB and furosemide were stopped with some improvement of the renal failure.
Moreover, PSA and a Myeloma Screen [renal failure, raised calcium and back pain] should also have been checked in view of being elderly and male.
The patient's back pain improved during the admission and there was no weakness of the lower limbs and he was subsequently discharged home for follow-up as an outpatient.

In summary,

1. Not all hyperprolactinaemia is due to an adenoma. Think of more common things e.g. drug induced renal failure, anti-dopaminergic drugs, lung cancer
   
2. In men, consider also osteoporotic fractures not just osteoarthritis.
3. Think of hypotestosteronaemnia, multiple myeloma, prostate cancer and hyperthyroidism as possible causes of vertebral fractures in men.
4. If you find back pain you must examine the neurology of the lower limbs, check sensation and do a rectal examination. Such patients require urgent imaging by Xray and MRI and may require urgent neurosurgery.
5. Remember, drugs can cause renal failure and the drugs should always be examined in detail and if there is a concern that they are the cause, they should be STOPPED. As in this case, the patient also had COPD and was also taking two bronchospasm-promoting drugs !!! e.g. aspirin and a beta-blocker. Other drugs such as ticlopidine / clopidogrel can be used in place of aspirin and beta-blockers used for hypertension can be switched to other classes such as a calcium channel blocker. If used for anti-arrhythmic purposes there are many agents out there that can be used in place of a beta-blocker.
6. Remember to Ask Questions from Body Systems Review- you will find symptoms that the patient never thought were a problem and that they never thought you would ask and it will save your patient and you too.
7. Men with osteoporosis due to hypotestosteronaemia may benefit from testosterone replacement and reduction of fractures with the use of bisphosphonate drugs or the newer recombinant human parathyroid hormone ( teraparatide ), which should be strongly considered in this case. Note: when starting testosterone therapy, prostate cancer should be initially ruled out because hormone therapy can accelerate this type of cancer.
   
8. Most compression neuropathies from intervertebral disc herniation improve with time, but if severe e.g. severe pain, loss of function, then disc surgery should be considered.
   
9. Remember, Rectal Examination, Rectal Examination and finally, Rectal Examination. Never Forget to Do It !!!!!!!!
10. In view that this patient had biochemical evidence of testicular failure, the genitalia should have also been examined. Never forget to examine this area.
    

One excellent reference for principles of history taking (and hence, Body Systems Review) is:
The Patient History: Evidence-Based Approach (Paperback)
by Lawrence M. Tierney & Mark Henderson

Please consider....

Juggling The Balls of Uncertainty

Dear Bloggers

A 70 year old female was admitted into another hospital in Japan, following 3 episodes of gastrointestinal haemorrhage.

She had first noticed dark, black stool the day before admission and she had slight lower abdominal discomfort.
However, by the next day, this was followed by fresh red blood on defecation. There was no information about how much bloody stool was produced.

The patient had no other symptoms including no nausea, haematemesis, vomiting, epigastric pain, dizziness, dyspnoea, palpitations etc...

The patient had known severe coronary artery disease and had had a previous myocardial infarction resulting in 100% stenosis of the RCA, LCX arteries and a patent LAD which housed a stent to maintain its patency. Not only that, an apical thrombus had been diagnosed due to dyskinesis of the left ventricle, several months before for which anticoagulation was used.

The patient was also receiving aspirin and ticlopidine but no proton pump inhibitor (PPI).

The patient was not using alcohol. There was no history of any previous GI complaint.

Previous medical history apart from the above also included Diabetes Mellitus (Type 2) for which a sulphonylurea was used for control.

She was a non-smoker.

On examination the patient looked unwell and pale. The blood pressure was 80/40 despite having received 3 litres of crystalloid fluid. Pulse was 120/min and regular. Temp 37.0
Resp Rate 14/min and O2 sats 97% on room air.

CVS: Pulse quality was reduced at the radial artery; it was difficult to find. Left hand middle and ring fingers were cold to touch. JVP was not elevated. No heaves or thrills. Heart sounds were normal. No peripheral oedema was found.

RESP: Trachea was central. Hyper-expanded chest. Slight crackles evident at the right base only.

ABDOMEN: Soft, non-distended, no organomegaly, palpable colon from faeces only. No rebound or guarding. Bowel sounds increased. Rectal examination: Fresh Blood and no masses.

Bloods revealed a raised BUN/Creatinine ratio, Hb 6.0, INR 3.0. Normal CK and normal Liver Function Tests (three hours before, the Hb was 11g.dl)

One area with highest risk from bleeding was the Upper GI tract such as the stomach or duodenum in view of the history of anti-platelet agents and malaena, although lower GI haemorrhage could not be totally excluded because of the lower abdominal discomfort that was non-specific. Sometimes, a caecal focus of bleeding can produce stool that looks similar to malena. A raised BUN to Creatinine ratio can signify upper GI haemorrhage but in this case it might also be as a result of renal hypoperfusion from shock-- there is simply no way to accurately tell unless a gastroscopy is performed !

However, this patient was not straight forwards because despite the bleeding, by reversing the coagulation might result in either stent thrombus or embolisation of the apical thrombus. This is a so-called Catch 22 situation i.e. you cannot win either way. You are damned if you do and damned if you don't..... :-(

It was clear that by not reversing the coagulation disturbance the patient would exsanguinate.

A senior doctor who reviewed the patient was suspicious that the combination of warfarin plus two anti-platelet agents was the cause for the bleeding. It was suggested that the following things should be instituted:

1. Blood replacement to aim for an Hb>10g/dl especially as coronary heart disease
   
2. Reduce the INR with Vitamin K (low dose e.g. 0.5-1.0mg only), plus Fresh Frozen Plasma (FFP) to aim for an INR of 1.5 or thereabouts
   
3. Intravenous Proton Pump Inhibitor
4. Stop anti-platelet agents (temporarily)
   
5. Urgent gastroscopy and colonoscopy. The former was suggested because of the raised BUN to Creatinine ratio.
6. Insert a Foley catheter to measure hourly urine output
7. Aim for systolic BP >100mmHg
8. Repeat echocardiogram
   

However, in the end, only Vitamin K was used and only a colonoscopy was performed which is shown below:

The colonoscopy showed generalised mucosal bleeding suggesting platelet dysfunction and coagulation disturbance. There was also evidence of Diverticular disease with bleeding, and although it is common for these to bleed, it by itself does not account for the generalised bleeding. Thus, the bleeding had resulted from an iatrogenic source-- DRUGS!

A gastroscopy was not performed and hence, an upper GI bleed was never excluded here.

Repeat transthoracic echocardiogram revealed that the thrombus located at the apex had become smaller in size as one would expect on treatment.

In this case, what one has to decide is which problem is going to be immediately life threatening, in this case, GI haemorrhage. Hence, once the bleeding had been stopped e.g. by clipping bleeding vessels and stopping harmful drugs temporarily e.g. aspirin, ticlopidine and warfarin and reversing coagulation disturbance, then treatment to prevent stent thrombosis / thromboembolisation would be the next step.

In view that the thrombus had reduced in size (and was more likely to be organising) and that with time, stent thrombosis is relatively less compared to the time when they are initially inserted, the relative risk of thrombosis/embolisation versus uncontrolled haemorrhage tipped the scales in favour of concentrating on stopping bleeding first. Remember the emergency ABC- without a Circulation the heart will have no blood supply for itself or for the rest of the body! Hence, stopping bleeding and maintaining the circulation is essential.

There were certain areas with this cases where management could have been optimised, for example:

• Performing Gastroscopy to exclude an upper GI source of haemorrhage (remember, there was malaena too and raised BUN/creatinine ratio!)
• Use of FFP-- essential. Reversing the INR (in this case, probably an incomplete reversal of INR would suffice) until all bleeding had ceased then followed by intravenous heparin for cardiac protection. Use of heparin is preferred in such circumstances because if bleeding recurs, the heparin can be immediately stopped and if need be, protamine sulphate can be used to reverse it. The only concerns here would be recurrent bleeding and the potential Heparin-Induced Thrombocytopaenia. HIT does not happen immediately and the risk increases the longer the heparin is used, usually over several days to weeks.
  

Vitamin K was used which would have returned the INR to near normal although it takes several hours for new clotting factors to come into play and this might be too late for someone bleeding rapidly. Always consider using FFP. FFP contains pre-formed clotting factors and hence, it will temporarily normalise the INR whilst Vitamin K allows new intrinsic clotting factors to be produced.

Hence, the idea that hoping to maintain a high INR for coronary protection and at the same time clipping bleeding areas in the face of generalised mucosal bleeding that could result in multiple torrential sites of bleeding at any time and anywhere needs a re-evaluation. It is like trying to plug holes in a kitchen sieve- a self-defeating objective. Not performing a gastroscopy again needs reconsidering because this patient had generalised mucosal bleeding and was probably bleeding from every part of the GI tract.

Remember, it is not just GI tracts that bleed on warfarin with dysfunctional platelets, anywhere can bleed, but especially the brain. The GI tract is a good guide (and the skin too) to know what is going on with coagulation in the rest of the body and with mucosal bleeding then be warned because your patient could have a intracerebral bleed. The important thing here was to control the clotting first and thereby control the bleeding to make the patient haemodynamically stable and then image the GI tract and then consider starting the heparin to protect the heart.

In this case, the patient's INR was reduced to 1.4 on Vitamin K alone and the repeat colonoscopy reconfirmed multiple areas of previous haemorrhage.

These kinds of case are not described in your average medical text book as no case is the same as the next. Doctors should always expect the unexpected and hope for the best, but plan for the worse. An element of uncertainty is always going to occur in a case such as this, and sometimes, keeping your nerve and following long-upheld evidence based rules but at the same time taking a leap of faith into the unknown is required in order to help your patient.

Please consider...

Medical Residency System In The UK

Dear Bloggers

It may well be known how the USA medical residency system works by Japanese residents because of the wide-spread American influence in Japan. However, I am certain that little is know about the UK medical residency system which I will endeavour to unveil in this article.

It may be best to explain the infrastructure of the system to see how it related to the residency system.

Basically, in a usual district hospital there are 10 medical teams which are usually Cardiology, Respiratory, Gastroenterology, Diabetes and Elderly Care medicine who although have their own speciality, they also practise General Internal Medicine and therefore see all medical problems.

Each respective team will usually have a first year doctor, and more senior doctor who may be anywhere from a second year to a fourth year doctor. There will also be a Registrar doctor who will be sometimes assigned to two teams within the same speciality thereby covering four doctors below him/her. These days, the number of Registrar level doctors has increased and therefore, it is likely that a Registrar will cover only one team. Each team has its own consultant who will also have a respective speciality and who also practises general medicine.

Each team will look after around 20-30 patients and the work will be split between the first year doctor and more senior doctor or they will see all the patients together. This thereby allows all the patients to be seen usually in a morning and all the jobs are carried out by the afternoon. If a patient gets sick then one doctor is available, usually the senior, to sort it out whilst the junior continues to see the other ward patients.

The Registrar is a more Senior doctor who is in training to become a Specialist consultant. The Registrars are usually engaged in a combination of Outpatient clinics and Ward work and hence, if patients are sick they are usually called upon to resolve matters especially if the less senior or junior doctors cannot solve the problem.

If all else fails, the Registrar may defer to the team consultant who has responsibility to try and resolve the problems.

Hence, there is an upward chain of command whereby the ultimate responsibility for all the patients lies with the consultant of the team. It is therefore in the consultant's best interest to know what is going on with the inpatients and this is done by twice weekly ward rounds in most cases.

The UK ward rounds involve the whole team seeing all the inpatients whereby the consultant can be updated on recent tests and blood results, but more importantly new history and physical changes. This is a great opportunity to learn as all the junior members of the team (everyone else lower than consultant level) have a chance to learn if they have been doing things correctly and get feedback from the consultant. This is also a safety mechanism for the patient as they will be seen by an experienced physician who will take more history and examine them and review drugs, interactions and start or stop such drugs. They will also make further plans and decide on discharge. Such an interaction between junior doctors, the consultant and the patient is a great opportunity for learning about history taking and physical examination but it also provides skills on how to manage inpatient problems, multi-organ system problems and how to decide on when to call the more senior doctor and when to discharge the patient.

Doctors do not stay in the hospital after 5:00pm if their work is finished. They are able to go home and rest--- or study !

If they are on-call, as a team, they will also admit ALL new medical patients referred from community GPs, other hospitals (transfers) and the outpatient clinic plus Emergency Room (Accident and Emergency [A&E]). Thus, all patients are admitted under the care of a single consultant on-call and that may be anywhere from 10 to 30 or 40 patients in a 24 hour period.

The on-call team work from 9am to 9pm and then go home. A night team who work for a week of nights take over from 9pm to 9am.

On the morning of the next day, the team do a Post-Take ward round to see all the new patients. Again, history and physical are reviewed by the consultant providing a great learning opportunity for the Residents. This is a legal requirement for all patients to be seen within 24 hours by a consultant when admitted to the hospital. This provides great training in emergency medicine.

On-call varies and may be once in a week or may involve a week of nights or a whole weekend, but no on-call session lasts more than 12 hours.

Why is this important? Well a fatigued doctor makes mistakes. A recent lecture given by Dr Landrigan in August 2007 at the National Institute of Health gives an indepth explanation of fatigue in doctors and increased chances of making medical errors and driving accidents after doing long on-calls and with sleep deprivation [ http://videocast.nih.gov/ram/ccgr082907.ram ]

Hence, the UK system having implemented the famous Working Time Directive has stopped most doctors working more than 56 hours per week.

I for one who worked under this system felt fatigued working 12 hours straight when on-call and was relieved to be able to get a good night [or day] sleep after on-call. I also worked under the old system which meant a full 24 hours on call or 72 hour weekend (Friday, Saturday and Sunday) without much sleep and hence, I know the acute differences that the Working Time Directive implemented and I am sure that it caused a reduction in the frequency of mistakes within the hospitals throughout the UK.

In the USA, some hospitals are trying hard to reduce doctors hours but they are by no means in line with the standards currently employed in the UK system.

In summary, the UK system has many doctors per team with a chain of command upwards when a less experienced doctor does not know what to do, which incorporates multiple checks and balances for the patient to try and avoid accidents and misdiagnoses. The consultant has a responsibility to see all new patients and all the inpatients, the latter, several times during a working week. Residents never work more than 12 hours at a time unless under exceptional circumstances and hence, it is hoped that this will reduce mistakes by doctors.

Resident educational is somewhat informal as it takes place during ward rounds and post-take ward rounds, but there are also educational sessions carried out by all the consultants on an ongoing rota once a week to teach specific topics. Moreover, the Registrars also do training sessions for the junior doctors and medical students.

Grand rounds take place weekly as do journal clubs. Other training for higher exams the doctors usually do Self-Directed Learning and they may also go on training courses. Registrars also go on specific training courses. For advanced exams (MRCP) the consultants and Registrars will usually rotate on a training scheme whereby they will take the senior doctors to a patient and ask them to examine a body system. They will then provide their advice and constructive criticism on how the doctor can improve their examination skills in order to pass this high-level exam.

The MRCP exam concentrates on history and physical examination with little emphasis on scans such as CT or MRI.

All training sessions take place at lunchtime in most hospitals with food provided.

Moreover, I have never seen a UK doctor fall asleep in any meeting.

In summary, I think that the UK system is comfortable for working in but also for having free time as well; the so-called Work-Life Separation. Doctors do not need to remain in the hospital out of hours as any problem is handled by the on-call team for that time, and that includes speaking with relatives.

There is an upward chain of responsibility by every member of the team and a very good but informal way of training the junior doctors on frequent wards rounds at the bedside plus formal teaching sessions.
Training focuses on the patient and not on interpreting radiological scans.

This is a different system to that found in Japan and such a system may be somewhat of a surprise to you.

Have a nice holiday :-)

Professor Tierney, Dr Aoki and Some Great Cases

Dear Bloggers

Today Professor Tierney visited our institution for just two hours, but it was two hours of brilliance.



The first cases consisted of a patient with pharyngitis, fever and shoulder pain. This was presented by our fourth year resident Dr Fukuda. Professor Tierney lectured on the quality of information about platelets and how you can predict either marrow failure or consumption just by observing the change in absolute numbers. The result of the case was meningococcal septicaemia with infiltration into the CSF without laboratory data indicating meningitis.


Professor Tierney and Dr Aoki were lecturing on how they had seen previous cases of meningitis without cells in the CSF; rare but still possible ! Never say Never.

However, during Dr Fukuda's presentation, he was being called to say his wife had just given birth to their second child--a daughter. Looks like Professor Tierney is a Lucky Charm too.




The second case presented by Dr Ban, was a very interesting case of a young female with a previous diagnosis of Diffuse PanBronchiolisis (DPB) and Immune Thrombocytopenic Purpura (ITP). The patient had been admitted with recurrent respiratory problems and there was a concern that the original diagnosis was in doubt.


The patient also had hypogammaglobulinemia.

Professor Tierney went through this case methodically and came up with differentials such a Histiocytosis X, Immotile Cilia Syndrome, Kartagener's Syndrome and potentially, Cystic Fibrosis.


However, pulling all the elements together, he considered that the initial diagnosis of DPB, made some 10 years before, was wrong and in fact, he considered it to be a congenital condition called Common Variable Hypogammaglobulinemia otherwise known as Common Variable ImmunoDeficiency (CVID).



I had also been consulted on this very same case a week before and my opinion was also CVID and it is good that two minds can think alike.

The disorder is rare and Prof Tierney admitted only ever seeing 2 previous cases in his whole career and this made his third.

UpToDate 15.3 covers CVID in some detail although I am sure any good medical textbook will detail this condition.

The two hours flew by and it was a shame that it had to end. Anyhow, there is always next year ! :)

Lastly, Congratulations to Dr Fukuda and his Wife on the Birth of their Second Child.

Hypoglycaemia masquerading as Hyperglycaemia !

A recent case at another hospital is a caveat for a common problem-- hypoglycaemia.

A female patient with a history of type 2 diabetes was admitted following several episodes of unconsciousness lasting up to 12 hours each time. The patient eventually presented to the hospital because of concern as to the cause.

On the first episode, the patient had collapsed to her right side with no associated seizures or incontinence. She awoke some 12 hours later.

The second episode, she collapsed whilst eating and again, this lasted some 12 hours. At that time, she was noted to be disorientated and could not remember how to cook or wash up dishes. She was also found to have some cerebellar dysfunction. These symptoms spontaneously resolved.

When she presented in the outpatient clinic, her blood sugar was high, approx 200mg/dl.

It was initially considered by the admitting doctors that it was an unusual neurological problem although the subsequent MRI was normal.

However, another doctor suggested examining the daily drugs that the patient took to see if these phenomena were drug-induced. Sure enough, the patient was taking metformin and glimepiride 1mg-- diabetes drugs !

One junior doctor suggested that this could not be hypoglycaemia because the admission blood sugar was normal-high and that the patient had no warning signs of hypoglycaemia. This reasoning was not correct for the following reasons:

1) Most cases of hypoglycaemia are drug induced e.g. sulphonylureas / alcohol / insulin and as a consequence, they can cause a decline in blood glucose levels. The reflex reponse of hypoglycaemia is the output of Growth Hormone, Adrenaline, Glucagon in additon to Cortisol, whereby there is glycogenolysis and gluconeogenesis. Of course, this mechanism then over shoots and causes hyperglycaemia. This is the Sygomni Effect and is often seen in the early morning e.g. 3am when the patient wakens with sweats or wakes up on the floor with a headache having had a nocturnal seizure ! Some patients don't get symptoms of hypoglycaemia. Either this is because of beta-blocker use and hence, the adrenergic response to hypoglycaemia is blunted or the patient has been having recurrent hypoglycaemia which is associated with reduced warning signs.

2) Hypoglycaemia can therefore self-correct through the correcting mechanisms described above and when the patient is admitted to hospital may have a low, normal or high glucose level. The latter two scenarios DO NOT EXCLUDE an episode of hypoglycaemia.

However, some patients blood sugar can go extremely low and they may experience neuroglycopaenia and subsequent brain damage and hence, hypoglycaemia must always be treated.

With such a history of prolonged unconsciousness with periods of normality punctuating such episodes in a patient with diabetes on hypoglycaemic agents, one must allows consider this to be drug induced until proven otherwise.

The glimerpiride drug is a once daily dosing 3rd generation sulphonylurea. Because of its long period of activity, it can induce hypoglycaemia. Metformin rarely causes hypoglycaemia by itself.

Hypoglycaemia should always be considered in diabetic patients who have an HbA1c <7% (DCCT-aligned) who take insulin or an SU drug. This was demonstrated in the DCCT study when the more intensive the diabetes was treated, and hence the lower the HbA1c towards to the population normal range, the higher the recorded refequency of hypoglycaemic events. In this case, the patient had an HbA1c of 6.8% (non-DCCT aligned) and hence, it is difficult to say exactly what the DCCT aligned HbA1c was without the appropriate adjustment to DCCT.

Patients with suspected drug induced hypoglycaemia should receive iv glucose infusion (50ml 50% glucose) and the diabetes medications should be halved in dose or in some cases stopped and changed to a shorter acting agent e.g. glibenclamide changed to gliclazide.

In this case, the glimepiride was stopped. It is better to allow the DM control to run slightly high for several weeks so as to allow the mechanisms for hypoglycaemia to auto-correct before trying to attain tight control again. Hence, earlier warning for hypoglycaemia can hopefully be restored.

Finally, patients with hypoglycaemia have to got through several steps to correct their hypoglycaemia 1) They have to have warning signs 2) They have to recognise those warning signs 3) They have to consider how to correct the problem e.g. decide to eat some food 4) They have to put the thought into motion e.g. eat some food.

Anywhere along the way, such patients can have a failure to correctly manage a step, resulting in hypoglycaemia being uncorrected. For example, a patient may have warning signs and recognise them but fail congitively to consider how to correct the problem or fail to eat food despite wanting to.

Remember: Patients with hypoglycaemia can present as unconscious, confusion, aggression, appear drunk, appear with hemiparesis or seizure etc.... CT / MRI are nice tests for making nice pictures, but never forget to check a blood sugar and check the drugs as something simple as 50% 50ml Glucose can correct the problem in seconds and save a life, and save embarrassment for you too.....

Please consider ! :)

Prof Tierney Back in Town

Dear Bloggers

Professor Tierney is back in Town. Today he began his 3-day whirl wind lecture tour at C.

There were three morning sessions organised, two of which Professor Tierney presented his own cases acquired from other hospitals in Japan. The middle session involved a case presented by the C residents to put Professor Tierney to the test.



In view that Prof Tierney may be presenting his other cases at his future hospitals in Japan, I will not reveal their contents. It is a surprise !

However, the C case involved a female who presented with an intermittent nocturnal non-productive cough, fever and hypoxaemia. The diagnosis was made from history and physical examination and later inferred by chest roentogen / CT, which was extrinsic allergic alveolitis. This was a simple diagnosis for this Professor of Medicine :)


One odd thing was the request of a resident to have Professor Tierney to sign his wallet!!! Perhaps the strangest request he has ever had !

Absence of Fever

The elderly are a unique subset of the patient population. When the elderly get sick, it is time to throw the book out of the window for adult medicine because there are not firm & fast rules.

When I say this I mean for example about sepsis. In sepsis, elderly patients do not always have a fever, they do not always mount a white count or even a rise in C-reactive protein.

Patients do not always get headache, Kernigs or Brudzinski sign in meningitis and alot of elderly patients have a stiff neck just from age related osteoarthritis rather than from meningism.

Hence, relying on the patient not having a fever, a normal WCC and CRP does not exclude sepsis.

Patients can present with confusion and low blood pressure and a tachycardia. The observations of the patient and looking at the patient from the bedside can sometimes be more revealing than the blood results.

Therefore, don't be mislead by seemingly normal blood results. Remember to always take cultures of blood, sputum and urine, and if warranted, CSF to check for meningitis / encephalitis or even stool culture / toxins.

A good example was of a recent case from another hospital of a male patient with a 3 week history of worsening cough. The patient had otherwise been remarkably well despite having severe aortic stenosis. However, the patient lost his appetite and the cough worsened precipitating a hospital admission. All the observations were normal. No fever, normal blood pressure and pulse and SpO2 was 96% on room air.

Even the white cell count was normal. CRP was only slightly raised at just above 1.

Examination was most revealing as the patient appeared weak and tired and slightly confused. Chest examination revealed dullness to percussion and crackles with the addition of increased tactile vocal fremitus. JVP was not raised but peripheral edema was evident.

The concern was of rather than just a straight forward pneumonia, it was considered that there could be heart failure plus pneumonia.

The patient's sputum examination revealed gram positive diplococci consistent with streptococcus pneumoniae.

Echocardiogram and BNP exams were also ordered.

In this case, the patient had a pneumonia plus suspected heart failure from severe AS. Despite these problems he only manifested loss of appetite, weakness and mild confusion. No obvious problem with his vital signs and no fever.

Please remember that patients do not write the textbooks---doctors do. A typical case is a typical case, but patients sometimes do not fit the mould and do not obey by the rules of illness as defined by doctors.

Hence, when it comes to the elderly don't just label them as demented when they turn up to your hospitals with confusion, it could be due to overwhelming sepsis!

Please consider.... :)

Back In The Saddle

Dear Bloggers

It has been almost 2 weeks since my last blog for which I apologise. Unfortunately, I was unwell and I underwent various and extensive medical tests. I am now getting better and I hope to be back to writing my regular blog articles from now on.

I have been extremely impressed with the speed of the medical services here at my hospital. The process of undergoing tests is streamlined and well practised. I have only ever been used to the British hospital national service which is also very good. However, when you become a patient in another country it can sometimes be daunting about what tests will be done and how quickly and particularly the communication. However, I can understand many Japanese medical terms these days plus usual communication, so I did not find that too taxing.

I have had no complaints at all. In fact, I was very, very impressed. I also noticed that people showed concern and were caring. Hence, the Caring Profession.

Although I have no wishes at all to be a patient, I did feel I was in good hands.

I am now Back in the Saddle..... :) It is sure good to be back!!!

Changes to this Blog

I have decided to make some changes to the design of the blog page and I hope that it is now easier to read than before.

This new format should now fit the entire page of your computer and the text should be easier to read than before.

I have also removed the restrictions on this site for posting comments. You no longer require a Gmail account and you can simply post a comment although all comments will be reviewed by me, the site moderator! :)

Be warned, I will only publish comments that are relevant to this site and not comments for people wanting me to advertise their books in America !

Please pass any feedback to me on how I might be able to improve this site in future.

Navy Meeting II: Journal Club

Last night we were invited to the US Navy base in Yokosuka to partake in their alternate month Journal Club.

We started the session with delicious American pizza with some refreshing beverages followed by the presentation of two recent journal papers.

The first paper was presented by one of this years interns and it featured the topic of male circumcision for the prevention of HIV transmission. This idea was put forwards over 20 years ago when HIV was first discovered but for some reason it has taken until now to have been taken seriously. The results of the paper and several others show a 50-60% reduction in HIV transmission rates simply by circumcising men. This, apart from condom use and total abstinence, is probably one of the major factors identified for reducing HIV transmission in sexually active men.

The second paper featured the topic of obstructive sleep apnoea-hypopnoea in children. The paper discussed about adenotonsillectomy aiding children who have the OSAH problem and where diagnosis with polysomnography can be helpful to determine those patients who require surgery and those who do not.

Both papers were quite long and somewhat complicated even for natural English speakers, but both Navy interns did remarkably well and spoke very eloquently with congent perspectives on the papers.

The US and British style of Journal club activity is more combative in style with questions and opinions being thrown at each other to see what other peoples opinions are in return. In a UK or USA type journal club setting, the opinion of the person presenting the paper should also be heard.

For example, the presenter may agree with the paper's findings or on the other hand, they may find other errors with the paper and disagree with the findings. Just by conveying the Author's opinions is not enough. As doctors, we can all read a paper and appraise it ourselves without a presenter.

The purpose of the presenter is to compare, contrast and constructively criticise the quality of the paper. There are many papers produced each year, some with dubious results, each trying to persuade us to change our practise in some way or other. If we were to believe everything we read then we would be pushed and pulled in sorts of directions and not necessarily the right ones.

A journal club is there to try and concentrate the presenter to give his or her opinion why they agree or disagree with the findings and then to justify that opinion. It is not always the best way to just agree with the Authors of a paper as the Authors may be wrong and have come to the wrong conclusions. It is sometimes good to be critical because as doctors we are presented with information from drug companies each and everyday who are trying to get you to use their drug and convincing you that their drug is the best for a particular condition.

When they provide you with the 'evidence based papers' you need to be critical of such studies and try and find other studies that agree or disagree with such findings. It is a real problem because drug company studies are generally funded by the drug companies themselves and they sometimes are in control of the data collection and analysis-- this is a gross conflict of interest that the medical professional has little power to do anything about. Hence, it is sometimes dubious as to whether we can believe the findings of such papers. Therefore, the purpose of a Journal club is to teach you how to critique a paper and how to pose questions to those who produce a paper or to drug representatives.

Asking drug reps how and why we should use their drugs and what evidence they have is not something to shy away from. When we use new a treatment we need to know that it works, it is better than the previous treatment, that it does not harm the patients and if it is more expensive than before, that it is going to prove cost effective and actually make a clinically significant difference in the long run.

Hence, a Journal club is not just a nice meeting for a friendly discussion, it is a serious thing that can teach us all a great deal and it is great to hear other peoples opinions even if they are different from our own.

These meetings are proving to be very helpful and provide an insight on how matters are discussed differently among different cultures.

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.

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 fooled.....as 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.

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.

Serial ECGs and Non ST Myocardial Infarction (NSTEMI)

Today's Blog is about the simple use of ECGs to make a diagnosis of Non-ST Elevation MI (NSTEMI).

Patients with a myocardial infarction can typically give the following history:

• Sudden onset central chest pain
• Worst pain ever in their life e.g. 10/10
• The pain is described as squeezing / a tight band / like someone sitting on their chest
• Pain may be epigastric in location
• Pain may radiate to neck / jaw / shoulder or down either arm although classically on the left side
• There is usually associated nausea, vomiting, sweatiness and breathlessness.
• Patients can collapse due to sudden dysrrhythmia

However, patients can present only with sudden onset breathlessness and no chest pain. These patients are typically diabetics.

Hence, it may be impossible to obtain an MI history despite asking all the above important questions.

Examination may or may not be helpful. Acute onset heart failure is often a clue.

On admission to hospital, the cardiac enzymes may be normal. These may sometimes be of no help acutely in MI as they take several hours to rise. However, they should still be performed on admission as they provide a baseline level and if the history is more than several hours, the enzymes may have already become positive.

The, perhaps, most useful and simple non-invasive tool is the ECG. It may sometimes be initially normal only later to show changes.

Therefore, in such cases it is essential to repeat the ECGs and compare them to previous ones such as admission ECGs or even previous ECGs taken some point in the past.

Such changes are usually non-specific T wave inversion and sometimes Q waves. These signify possible myocardial damage.

As I have mentioned in a recent blog article, it is often necessary to perform a Troponin T test despite normally looking CK and CK-MB fractions especially after 6 hours.

For example, a recent case of a patient admitted with breathlessness with a background of chronic renal failure, old MI and diabetes mellitus had no chest pain or other symptoms of AMI. The patient had recently been having intake of more fluid than normal and had not had haemodialysis in several days. Hence, the heart failure that was found on examination and seen on chest X-ray was assumed to be due to fluid overload.
However, when one looked at the ECGs, the initial ones showed a tachycardia. But several hours later the T waves had inverted thoughout all the anterior and a few inferior leads suggestive of wide spread ischaemia likely due to a left main stem lesion.
Echocardiogram showed an EF% of 40% and generalised hypokinesis.

The CK level was only mildly elevated and CK MB was normal. However, after several hours the CK was further raised followed by the CK-MB and AST. A Troponin T test was then requested.

In patients with Chronic Renal Failure / Diabetes they have an increased cardiovascular risk and patients developing breathlessness should not just be assumed to have fluid overload before completely excluding AMI. In such patients checking serial ECGs and Cardiac Enzymes is essential.

Treatment for AMI (NSTEMI) in the acute phase [within 24 hours] include:

• Aspirin
• Clopidogrel (recently introduced into Japan but used for several years in Western Europe; 300mg orally followed by 75 mg daily)
• Statin Therapy e.g. Simvastatin 40mg / Atorvastatin 10mg even if the cholesterol is normal. Statins have been shown to help stabilise plaques and improve the outcome of coronary artery intervention. It is regarded as an acute treatment to be started the same day.
• Beta-blocker e.g. iv beta blocker followed by oral e.g. bisoprolol / carvedilol / metoprolol unless patient has asthma / COPD / Severe heart failure. Beta blockers have been shown to reduce mortality post-MI. They should be started the same day.
• ACE-Inhibitor e.g. Ramipril. These should alse be started the same day. They help myocardial remodelling and in heart failure reduce the readmission rate and improve survival.
• Heparin / Low Molecular Weight Heparin to be continued for 48 hours after pain has settled.

The above is the basic standard for AMI treatment (see the European Resuscitation Council Guidelines 2005)

Remember: ECG can be normal. CK and CK-MB can be normal. Troponin-T can be positive and still be an NSTEMI. You must have a high index of suspicion. Also, please use the TIMI scoring system which ranks people into High or Low Risk and such High Risk patients still require investigation and workup for coronary disease.

Please consider.

Arms and Legs

Today this blog features on how doctors examine their patients.

In the main, doctors commence their examination by starting with the Head, Ears, Eyes, Nose and Throat (HEENT). They then progress down to the chest and abdomen to complete their examination. This is the first problem...

If the arms and legs are not examined then the patient clinically has no arms or legs ! By not examining the limbs, the doctor can miss very important physical signs.

Normally, the observations are performed by nursing staff by taking the pulse, blood pressure, respiratory rate, SpO2 and temperature. These readings are normally performed on an automated machine. Here is where the next problem comes in ! By a machine taking the readings the doctor no longer takes the pulse or holds the hands and thereby misses salient clinical signs.

The pulse rate is not the only thing that one looks for when examining the pulse. The quality of the pulse is very important that a machine cannot measure so easily. When I mean quality I mean the strength and dynamics of the pulse e.g. weak pulse or strong pulse. The pulse may be slow to rise during systole or may have a brisk upstroke and then collapse, the former which may may signify Aortic stenosis and the latter Aortic regurgitation respectively. Moreover, a collapsing pulse can also be associated a hyperdynamic circulation as I have previously discussed.

An excellent example was a recent case of a patient with a fever who was being monitored. The pulse rate on the screen said 156 beats per minute. For some patients with a fever, this would not be unusual. However, when the pulse was measured, it was 84 per minute. In fact, when listening to the apex beat, it too was 84 per minute. The machine was wrong ! Yes, the machine made a mistake. Hence, relying on a machine may give you inaccurate information. You must recheck the observations by taking the pulse by hand.

Moreover, failing to check the hands you will miss clubbing, splinter haemorrhages, Janeway lesions, palmar erythema, metabolic palmar flap, so on and so forth, as just a few important examples.

Failing to examine the lower limbs and moreover, failing to remove bandages and socks, you will miss ulcers / infections / gangrene / DVT -- always take off what is covering the skin. In the UK, I saw many cases of severe medical problems being covered over by bandages, socks and even newspaper!!!!

One example was a male patient with a painful lower limb and who was vomiting. On examining his leg, which was covered in newspaper because of the leaking fluid, it was found to be critically ischaemic. The patient was vomiting from septicaemia and needed immediate surgery--which he refused. Other examples have been severe ulceration of the surface tissue down to the bone and a patient with gangrenous toes -- all covered by bandages. Bandages don't make the problem go away, it just makes us want to ignore it. However, when we see a bandage / socks, we should remove them and look at what is there !

Also, in the bed bound patient please check for decubitus ulcers. There was a case of a patient with recurrent fever at a nearby hospital who had no obvious focus. However, when the patient was rolled to the side, a decubitus ulcer was present on the sacrum and culture revealed MRSA. An isotope bone scan was advised to look for evidence of osteomyelitis. Such patients should be nursed on an airbed but failing that, pressure areas should be dressed and the patient turned regularly to offload pressure from such pressure points.

In summary, I would advise doctors to commence their examination by looking at the hands, taking the pulse, and move upwards to the head and then down the body to end at the feet. In so doing, the whole body is examined and simple diagnoses will then not be overlooked e.g. lower limb cellulitis as a cause of fever.

Please consider......

PDAs in Medicine Revisited

I have written about the use of PDAs in everyday medical practise in the past, but I would like to revisit that topic once again.

I was recently consulted by a junior doctor about the advantages of using Pocket PC devices which run Windows Mobile software-- here is a summary of my answer.....

Well, currently there has been a massive explosion of PDAs coming onto the market running various different operating systems including: Windows Mobile 6, Symbian, Blackberry, Apple (iPhone / Touch) although not the good old Palm OS [which has not changed in a long time !].

Which platform do you choose from such a wide choice?? Well, I perhaps have an answer. It really depends on what you want to use it for. If it is for lots of medical books then the Pocket PC devices are currently what I would recommend. For example, Skyscape products (www.skyscape.com) provide medical texts for Palm, PPC, Blackberry and iPhone. From my experience, the Palm version texts can cause the Palm device to crash (examples Clie NX80, TH55, Palm LifeDrive), which does not appear to happen on PPC platform.

I have no experience of the other platforms running this software so it would be inappropriate to comment further. However, Skyscape products are Excellent !! They have all the major manuals covering every area of medicine. I would highly recommend visiting the site to see for yourself.

Some good books to check out are the Oxford handbooks, Merck Manual (very good !), Harrison's Manual, MedConsult (Prof Tierney's text) and the Washington Manuals....see for yourself. They are downloadable as trial software so you can test them and see how good they really are!

UpToDate is a relatively pricey text if one compares to a standard textbook, but the fact that it is updated several times per year and that it is highly referenced with Evidence makes it a worthwhile addition for any serious physician or department. It is also available on Palm (not Clie devices) and Pocket PC. However, the other platforms are currently unsupported.

Moreover, Pocket PC can also run the Palm OS 5.0 equivalent software known as Styletap (www.styletap.com) and this enables Palm lovers to run their Palm OS software on top of a Pocket PC software structure and at the same time they have the added bonus of Multi-Tasking as Windows is running in the background, which was absent on the pure Palm-based systems.

With new machines coming with up to 8 or 16 GB as standard (HTC X7501 8GB, Apple ipod Touch) and more and more books can be stored electronically then the current Palm based devices have lost the competitive edge. By having a PDA with electronic books, it enables checking of information on the move e.g. on the ward, at the bedside, whilst travelling or even sitting at your empty desk. Yes, it will be empty as you will not longer need paper books :)

The PDAs currently running Symbian or Blackberry are gradually being catered for by medical text solutions, but it may be sometime before they can fully compete with the Windows selection of products.

The most interesting thing at the moment is the ipod Touch but it lacks a microphone (hence, no dictation ability on the ward), no bluetooth (no A2DP wireless music), no Infrared (no beaming of documents), but for multimedia purposes and of course, MP3 it is seemingly very good. It does have Wifi which means online texts such as UpToDate can be accessed---but you need to be in range of a Wifi connection !!
As the product line matures and more medical texts are produced for it, it may be the next PDA to invest in.....

Bottom Line: I would currently recommend buying a Pocket PC running Windows Mobile 6 for your daily use of electronic books, note keeping, word processing, email etc.... The higher range devices are fast, stable and are obviously compatible with the new Vista OS. The Palm and PPC devices have the largest amount of software produced although the PPC platform has edged ahead and the PPC devices are proving to be more stable.

Please consider :)

US Navy Medical Meeting

Last week was our first combined meeting with the Yokosuka US Navy doctors and their Japanese residents.

The meeting was well attended and there was a long and short case presented by the two Third year residents from this hospital.



The first case was a work-up for Fever of Unknown Origin which, in the end, was diagnosed as a lymphoma. The short case was for work-up of non-specific symptoms such as myalgia, mild fever and raised inflammatory markers which was diagnosed as a vasculitis.


The two third year residents spoke completely in English and were able to answer the excellent and direct questions from the US Navy doctors and residents, which generated very good and informative discussion.

The Third year residents did extremely well especially as it was their first time to present in another language!!

After the meeting we had a party, and for one new member of the US team who has recently come to Japan, it was his first time to see live sashimi.... unfortunately, he was not inclined to eat it, but it was delicious !! :)


These combined meetings are planned to occur on a monthly basis and I see this as a great opportunity for learning English presentation skills, how to answer medical questions in English under pressure and to discuss similarities and differences in disease presentation, investigation and treatment in an Evidenced Based Environment.

This hospital's Internal Medicine department is now probably one of the most unique facilities in Japan and it not only offers daily teaching in English from me, but it now offers a monthly American addition and it is a most exciting time to be at this institution !

Photos courtesy of Dr Shin Fukuda

Cardiac Enzymes and the TIMI Scoring System

Just how reliable are cardiac enzymes?

When working up a case of acute coronary syndrome it is usually the case that CK and CK-MB are tested.

In a typical ST elevation MI, CK and the MB fraction will rise. However, now with the more specific cardiac biomarkers of Troponin-I and Troponin-T it is now possible to identify myocardial damage even when CK and MB fractions do not indicate an MI.

Such cases can involve the Non-ST elevation MI (NSTEMI) situation in which such patients may also have a normal ECG. I have seen this on a few occasions in the UK.

Other ECG abnormalities can be shown by non-specific ST changes, such as flattening, sinusoidal ST morphology and little else on occasion.

On some occasions the CK does not rise BUT the troponin is positive >0.1 consistent with an infarction.

Hence, measuring CK-MB fraction in a patient with a suspected acute coronary syndrome would seem obsolete especially when there is a more specific cardiac marker available such as the troponin test and which remains elevated for longer.

The Troponin test is not immediately positive and can take at least 6 hours before it rises, but it can persist for up to 10 days.

Hence, if you suspect an acute coronary syndrome (ACS), in addition to checking a CK level, it would also help in assessing a troponin level after 6 hours, if that utility is available.

Troponin levels have a direct relationship with 30 day mortality and patients should be treated as high risk for further cardiac events.

Troponin levels can be raised in renal failure and the higher the level of renal failure the higher the troponin. However, renal failure is also associated with increasing cardiac risk and hence, a raised troponin in renal failure should not be ignored.

CK and Troponin can also be raised by myocarditis and pulmonary embolism and hence, in situations when patients develop chest pain diagnoses such as AMI, PE and myopericarditis should be considered if these cardiac markers are raised.

Finally, patients with chest pain can be risk stratified into low risk and high risk groups which predicts further cardiac events after either NSTEMI / Unstable Angina or following an STEMI. Such TIMI scoring systems can predict the likelihood of further cardiac events within a 14 or 30 day period respectively. High scoring patients need further and more intensive investigation and treatment. The NSTEMI / UA scoring system can produce a High Risk score even when cardiac enzyme markers are normal and hence, patients should be treated with the similar treatment intensity as those patients who do have raised cardiac markers as the risk scores can be the same.

The STEMI scoring system does not include cardiac markers as the assumption is that these are already raised because of the nature of an STEMI. However, on occasions, STEMI can be aborted with successful intervention treatment and where there is no cardiac enzyme rise although this is the exception rather than the rule.

Hence, for example, a 65 year old patient with > 3 coronary artery disease risk factors and who is taking aspirin and who develops cardiac chest pain without ST change and with no rise in cardiac enzymes scores 3 points making this a High Risk patient and with an approximate 13% 14 day risk of death or new / recurrent MI or severe recurrent ischaemia requiring urgent revascularisation. Such patients in England are very common. Typical patients are elderly angina sufferers who have cardiac risk factors and who are taking aspirin and many other medications for angina. However, they should be taken seriously as they are High Risk for further events. As a result, such patients should receive intensive medical therapy such as heparinisation, additonal anti-platelet therapy e.g. clopidogrel, anti-anginal medication, statin therapy and early percutaneous coronary intervention if available.

It is therefore safer to keep such patients in hospital rather than sending them home when the CK / CK-MB / Troponin T are negative, until their condition has stabilised on treatment and it is deemed safe for them to leave after a thorough work up and exclusion of serious pathology.

The take home message here is if the CK / CK-MB is normal, it does not exclude acute coronary syndrome. Always check a troponin at least 6 hours after an episode of chest pain-- you may be horrified to find it raised despite the normal CK.

Lastly, even if the cardiac enzymes are not raised, it does not exclude the patient from being High Risk for a future cardiac event with 14 days, as predicted with the NTSEMI / UA TIMI scoring system. Such patients should be fully assessed, investigated and treated the same as for any patient with a cardiac event with raised cardiac markers.

Please check out the NSTEMI / UA and STEMI TIMI scoring systems online by clicking on the words outlined in blue above which will link through to those internet pages respectively.

Please consider....