January 30th, 2012
We asked you about this case of a 37 year old intravenous drug user with suspected bells palsy.
And after reading his case, the diagnosis is:
d. Ramsay Hunt Syndrome
Firstly this is a lower motor neuron (LMN) facial (CN VII) palsy: facial weakness of the whole of the face.*
Bell’s is a lower motor neurone lesion which is idiopathic in nature.
The aetiology is probably thought to be a herpes virus and there is some evidence to support the use of short course oral corticosteroids and aciclovir.
- about 50% of people will get better with no treatment
- steroids for approximately 1 week seem to help 50% of cases
- the benefit of aciclovir remains controversial
Read the Bandoleir review here
However: Ramsay Hunt is a facial nerve palsy caused by associated herpes zoster infection (as manifested in this case by the vesicles). When a patient presents with a CNVII weakness, this is one of the key reasons to perform otoscopy, as otherwise you may miss the vesicles.
*Remember in UMN lesions the upper half of the face (highlighted here in yellow) is spared as there is bilateral UMN innervation. You would not expect this in Ramsay hunt as its a LMN lesion. The image below shows a LMN CNVII weakness.
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January 5th, 2012
A 37 year old intravenous drug user is referred by his GP for a suspected Bells Palsy. On examining his inner ear there are a number of vesicles visible on his ear drum. His cranial nerve examination reveals a weakness of the whole of the left side of his face.
The most likely diagnosis is:
a. Steven Johnson Syndrome
b. HIV
c. Stroke
d. Ramsay Hunt Syndrome
e. Bells Palsy
Leave your answer as a comment below – answer in a few days!
November 9th, 2011
The average medical student debt on graduation has risen from £23,909 to £24,092, the British Medical Association (BMA) reports.
Photo by upsuportsmouthPoorer medical students’ debts have also soared. Those from low-income backgrounds graduate over £13,000 more in debt than better off students – graduating with a projected debt of £37,588 (up from £26,324 in the past 12 months).
The survey from the BMA also reports that the number of medical students from the lowest income brackets is in decline over the past 12 months.
Co-chairwoman of the BMA Medical Student Committee Elly Pilavachi said:
“Medical students are now facing extremely high levels of graduation debt. Many are clearly heavily dependent on financial support from their families and friends to get through the intensive, five to six-year medical course. However, the picture for those from low-income backgrounds is particularly alarming with their debt levels a staggering £13,000 higher than those from higher income brackets.”
Clearly there is a lot to think about if you are planning on becoming a medical student, or already are one. What do you think about the current financial plight of med students?
July 2nd, 2011
A 62 year old man presents with a swollen right calf 3 weeks after undergoing a total left hip replacement. He is known to have rheumatoid arthritis.
An Emergency Department doctor tells you that he feels the patient can be discharged. He tells you this because he shows you the D-Dimer result, which is “negative”. The result is shown below.
| D-Dimer 0.08 (Normal range 0-0.18) |
Which of the following statements is true about D-Dimer testing in general patients with a suspected DVT?
a. Following a clinical assessment, clinicians should not rely on the test as a basis to ‘discharge’ or ‘investigate’
b. It is of no use in patients who have had recent surgery (e.g. within the last 12 weeks)
c. It is of no clinical use in patients with malignancy and secondary metastases
d. It can be used to discharge patients based on their underlying estimated clinical risk score
e. None of the listed answers are correct.
Leave a comment; answer in a few days!
May 18th, 2011
The emergency department is the frontline of medicine, and as with any soldier you’d better be ready to give your life for the cause, says Dr Will Dawson, GP Trainee working at the West Yorkshire Deanery.
Emergency medicine (EM) is a common rotation during foundation training and GP training. It is a far cry from most of the things you have done before, and can seem an intimidating and terrifying prospect – new doctors need to know how to survive.
Fasten your seat belts, it’s going to be a bumpy night
Be ready for a hard slog and not just for yourself. EM is well known as an unforgiving rotation – especially with your time. Be prepared to sacrifice nearly all your extra–curricular activities and weekends, as you learn how to adapt to a different way of living. You will learn to make the most of your days off; just remember to book them – this is best done before you start the rotation.
Remember the anti-social hours EM requires does not just affect you; it can be your close friends, partner or family who struggle the most. Make sure your partner and family really understand the state of play. Nights and often weeks of spending little or no time with you is always surprisingly difficult, especially if they do not have a medical background, so it is important to spend quality time with loved ones whenever possible.
And as I was warned on starting my rotation, if you have relationship problems they are not going to get any better.
Be professional, be respectful and don’t be late
Teamwork is a crucial part of EM. Be punctual; it is important to be on time, and that means being dressed and ready and picking up your first patient card as your shift starts. It may sound obvious, but in such a pressurised environment no-one likes tardy colleagues at handover. After an exhausting shift, the last thing you want is your replacement to be late.
Yes, you are a doctor and “in charge”; however, most of the other medical staff will have years of experience and technical ability. If a member of staff suggests something or questions your management, do not just dismiss them. They have probably been doing it longer and could even – gasp – be right.
Remember that nurses are not your servants. Do not demand they do investigations that you could easily do yourself, especially if they are busy. If you can help them with jobs, it will pay dividends. Most will do basic investigations and cannulate patients if they are able to, but will not thank you if you order them to do so when they are rushed off their feet and you are enjoying your break.
Treating all colleagues with respect, and discussing the management of patients with those who are expected to carry it out, will help you get on better with others and get things done quicker.
Communication, communication, communication
We all know that good communication is of the upmost importance. However, multiply that by a million in EM. Due to the critical nature of patients, capacity and time restraints, everyone wants to know what is going on with your patient. Keep quiet and pretty soon you will have the nurse in charge, consultant and bed manager breathing down your neck wanting to know why your patient has not been referred or discharged.
If you have questions, get them out early on. Most registrars and consultants are very approachable and keen to help; however, you won’t be thanked for asking for advice for a patient you have been seeing for the last three and a half hours.
Telling your colleagues what you are doing will put them at ease, speed up treatment, and confirm you are doing the right thing. This also applies to patients – let them know what you are doing so they don’t feel left out.
Decision time
For most junior doctors, this is the first time they will have to start making decisions on the management of patients. You will be using your knowledge to assess and treat patients and make them better. Remember you trained for five years to do this, not to dictate discharge letters and write in the notes on ward rounds.
No-one is expecting you to know everything. Simple immediate, appropriate management is the name of the game, so do the basics and if you are unsure, ask for help early on.
Take a focused and appropriate history and examination. Think about the investigations you are doing and how they are going to affect your management. If they aren’t going to, then maybe you should not be doing them.
Read up on local protocols and guidelines – they will provide you with safe, appropriate and legally–defensive advice on treating many diseases. They are ideal for treating straightforward cases without bothering your busy seniors, but remember they are just a guide.
Always try to have a diagnosis and initial management plan in mind before discussing a patient with a senior, especially a consultant – they will ask you. I heard one consultant tell an SHO “you have your own GMC number, I am not deciding for you”. Remember, although seniors in EM tend to be the most helpful and approachable of all specialties, their patience will soon wane if they are asked to review all your patients.
Documentation
Time is not on your side, and often you will do many things in the heat of the moment. However, it is important to keep your notes concise and precise. You may not be writing pages and pages, but you must document your assessment and treatment and the reasoning behind it.
Good documentation is your best defence should something untoward happen or a complaint be made. Remember to record not just your history and examination, but any discussion that you have with seniors or other specialties, and also that you have considered differential diagnoses.
When handing over at the end of your shift, you should give a clear plan of what is to happen with your patient. Handing over a patient should not be an excuse to hand over the decision-making. A clear plan also protects you when leaving your shift and makes sure that your management is followed through.
Work hard, but take your breaks
You may have done a wonderful job with your first patient of the day, but that does not mean that you can sit and wait for the investigations to be done. You will be expected to deal with more than one patient at a time. While you are waiting for the bloods you can start assessing other patients, or reviewing the previous results. But be sensible and don’t overload yourself or you will miss things, delay treatment or get things wrong, and patients’ management will suffer.
Remember to take breaks. It is up to you to do so; noone else will remind you. Check with colleagues so you do not all disappear at the same time, but do not be tempted to wait for a quiet moment, as some days it will never come.
As important as it is to arrive on time, try to make sure you leave on time too. This means being organised towards the end of your shift. If any patients need to be handed over, do so in good time to an appropriate colleague. If it gets to ten minutes until the end of your shift, it is probably best if you avoid seeing a new complex case, so ask if you can help with any jobs, or ask your seniors if there are any patients that it will not take too long to see.
There will be times when you stay longer, due to a busy department or a complex patient; however, be sure to log your hours, and make sure you will be paid for the extra time.
Enjoy it
EM may be something you never considered as a career, but make the most of your time there and you will really enjoy it. This is a time when you can grow as a doctor, in confidence and capability.
You will gain a wide variety of medical experience and skills you will not get anywhere else, from suturing to psych assessments.
You will develop new and better ways of working as a team, dealing with patients, and most importantly you will go from a TTO–writing and ward round–documenting encyclopaedia to a thinking and decisive doctor. Be warned you may find yourself not wanting to leave.
….oh, and there will be blood.
Having the right indemnity is vital for every specialty, but none more so than emergency medicine. If something does go wrong, or you need urgent medicolegal advice, MPS has a 24-hour medicolegal helpline that is available to all its members. Become a student member for free.