Monday 28 June 2010

64 year old man with 5 days of breathlessness

adam presented an interesting case of a man with a 90 pack-year history of smoking and a short history of breathlessness


we discussed the most likely causes, namely LVF [secondary to something], COPD and pneumonia


as there was little evidence for these conditions, we pursued other diagnoses, eg PE, anaemia [secondary to something] and cancer


we discussed the distinction between massive and peripheral PE, including examination & ECG features of right heart strain


here is the classical SI QIII TIII, taken from ABC of clinical electrocardiography, which is a useful resource [we should have mentioned AF as a common ECG presentation of PE]




he also briefly mentioned hypercoaguability, something worth knowing about

adam it would be good if you could upload an anonymous image of his acute ECG & the most relevant CTPA image [with arrows if possible]


homework generated included:


- causes of breathlessness [kumar & clark, harrisons, cecils, cheese & onion, medicine at a glance and beck et al were mentioned as things to read - paul dilworth's lecture is also a possibility - eric beck is a PDS tutor at the whitt & basically invented the MRCP - very good clinician, co-author diana holdright is one of your cardiology consultants]
- causes of metabolic acidosis
- wells score (or geneva score) for DVT/PE


most important, it is vital to follow this chap up to see what happens to him - this is the only way to get a full picture of what is going on

Monday 21 June 2010

neurological examination

this is not easy!

while most of you know the sequence [what was the PALS pneumonic? - TOPCAR??], there are real variations in technique, and without good technique signs are missed

this applies to doctors (like me) not just medical students

the chap we saw was wasted proximally, with low/normal tone & symmetrical weakness 4/5 of hip & knee flexion

he had +++ reflexes at the knee & ankle with upgoing plantars

we did not really test sensation properly - he seemed to have intact JPS

he was wobbly on heel-toe walking & his heel-shin co-ordination was poor, although this may be due to his reduced power
_ _ _

in my non-expert mind this does not fit together neatly!

if he has stiff then this would fit better with a UMN/cord lesion, although the pattern of weakness is not typical

he has a proximal myopathy, but classically reflexes are reduced

i will wait to see what happens!
_ _ _

in the meantime i will try to have a look at one of my favourite textbooks (by john patten)

[this really is a work of art - some incredible drawings]

another very good (short) book is by geraint fuller

2 websites:

1) from the university of utah has a great collection of videos (normal & abnormal)
2) associated with an excellent neuroanatomy book by hal blumenfeld

the link to the karim meeran vodcasts is here


Salaam

sabih

homework this week

izzy - causes secondary hypertension

adam - ECG learning resource

leena - (patho)physiology of angioedema

amanda - still waiting for a good resource for learning ABGs and a quick lesson on how to not kill someone with a sickle chest crisis


a 28 year old west african with acute renal failure

a very interesting case this morning - thanks saaid

things to learn:


  1. features of anaphylaxis
  2. features of angioedema
  3. what is C1-esterase inhibitor deficiency
  4. emergency management of acute renal failure (how did we know it was acute?)
  5. investigation of acute renal failure
  6. ECG signs of hypo- & hyper-kalaemia
  7. indications for urgent dialysis
  8. causes of low Na
  9. causes of low K
  10. causes of low platelets
  11. causes secondary hypertension
  12. clinical features of aortic dissection (benton episode - anyone know? also of note is that gerard houllier had an acute dissection in 2001)

things i learnt:

- 1 patient can teach us a lot of things
- following up patients is crucial, if we never put together the whole story, ie one with and 'end' we never really understand things
- those algorithms about what to do if x happens are only good up to a point, what you/i need is awareness of those algorithms + experience of applying them to real people

questions:

- if he had not had a reaction to a medication would he be dead now? [are we sure it was drug-related?]
- if he came into casualty tomorrow & you were the house officer, would you know how to treat him?

resources:

- davdisons cases has a good case about C1-esterase inhibitor deficiency

anyone find anything else?

Monday 14 June 2010

homework (amanda & arun) & apologies

apologies for not seeing you at the end of the day today - got caught up in finals-related planning

as i remember we had to update on:

- causes of aortic regurgitation (in a memorable & useful way)
- how not to kill people with a sickle chest crisis

arun & amanda: can you add your responses as comments to this post please?


Salaam

PS can someone please forward a link to this site to louis - we had to investigate pulsus paradoxus

clubbing, weight loss in an elderly male smoker

anyone else want to add anything by commenting?

the main issues were:

- clubbing & its diagnostic utility
- the significance of clubbing & tar-staining in an elderly smoker
- the difference between MR & AS as systolic murmurs [how would you tell these apart?]
- the work-up of weight loss & diarrhoea
- the causes & consequences of loneliness

it is important to find out what happens to this chap


Salaam

breathlessness in a 72 year old man

saaid presented a case of an elderly gentleman [did we get his ethnicity? - see previous post] with a short-ish history of breathless, and a significant history of past PEs


we reviewed the aetiology of SOB, dividing them into hyper-acute, acute and chronic causes


an systematic division (cardiac, respiratory, chest wall, neurological, haematological etc) was also noted


we noted that diagnosis of PE is best based on a formal scoring system, eg wells & geneva, and that clinical features of PE & alternative diagnoses are part of the score [there are data showing the appropriate use of scoring leads to fewer repeat events, eg roy et al 2006]

this gentleman had emboli confirmed on CTPA


we briefly discussed investigation, in particular examination, CXR & ECG findings. we did not look at D-dimers or VQ scans - he was severely hypoxic but not retaining C02


we briefly discussed LMWH, warfarin, thrombolysis & embolectomy as therapies

[as an aside this gentleman had a troponin of 0.2 - is this significant?]

i mentioned the algorithm in davidson's 21e as being useful


as lessons, we raised the following issues, amongst others:


- presenting patients/summarising patients
- ABGs
- causes SOB
- NYHA classes
- investigation PE


as action points, we endeavored to:


- list causes aortic regurg
- find out how not to kill patients presenting with a sickle chest crisis
- improve our skills in ABG interpretation by finding a good learning resource & looking at patients' results
- find out if there is a NICE guideline on PE (i don't think so - the is a BTS guideline)
- review Dr Dilworth's lecture on SOB
- read various bits of Kumar & Clark, Baliga [not only is he a professor in ohio, he also has an MBA!] 
- review Medicine at a Glance
- see more patients with PE
- follow up our patient







SNPing scientists

OK - i make no apologies for this post, even if it is not going to directly improve your performance in the end of year exams, this is such an important topic that i cannot let it go.

i find it laughable that you can graduate from 'London's Global University', the 4th best higher education institution in the world, with 3 science degrees (MB, BS, BSc), without knowing the significance of a SNP!

for those of you who might want to do science properly, this is crucial, for everyone else, this is part of the future of medicine

wikipedia has a simple explanation [be careful - the first google link takes you to the scottish national party]

Science hailed human genetic variation as the breakthrough of the year in 2007, and the lancet among others had the wellcome trust case control consortium genome-wide association scan as its paper of the year

[interestingly enough its breakthrough of the year 2009 was Ardipithecus ramidis, an early hominin species, that researchers published on last october (suwa et al, 2009) - they found a skeleton in 1994 & spent 16 years examining it - 'Ardi' a 50kg female lived 4-4.5 million years ago, about a million years before Australopithecus Lucy]

as william summerskill put it in an editorial:

"Despite the many excellent papers from prestigious scientific and medical journals, the choice this year was remarkably straightforward. After ranking the papers, more than half of The Lancet‘s editors had the same first choice: The Wellcome Trust Case Control Consortium’s Genome-wide association study of 14,000 cases of seven common diseases and 3,000 shared controls. Indeed, as soon as this study was published, the fi ndings created repercussions in the medical,6 scientific, and popular press."

the point about SNPs is that they represent a new way of working out human variation, one that was only possible because of the human genome project. more methods are coming, eg epigenetics. this is currently where we are at when it comes to 'personalised medicine', the holy grail of targeted, individualised diagnosis & therapy

when it comes to COPD, there has been some interesting work, for example looking at variants of an enzyme that breakdown extra-cellular matrix (MMP12), hunninghake et al 2009 (+ accompanying editorial by brusselle).

in this study a minor allele [do you know what this is?] was associated with some protection from developing COPD




there have been other studies looking at this & other genes on COPD & asthma (eg sleiman et al 2010, moffat et al 2007, he et al 2009)

a quick search on HapMap shows that the frequency of the AA genotype varies with population, for example 98% of the Japanese population have wild type AA (& therefore higher risk), while in the European population (actually taken from resident in Utah) it is only 80%

does this mean that Japanese people are at higher risk for COPD?

maybe - but MMP12 is only one part of the puzzle

whatever the answer in COPD, our 'stock' has a direct bearing on our health (& diseases) - and that is one reason to be aware of where we came from


Salaam


sabih