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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The saying goes “what happens on tour stays on tour”, but when posting online bear in mind that what happens on Twitter stays on Google forever. Doctors should exercise caution when making entries on social networking sites – the internet is not a private space and nothing is truly anonymous.

Photo by Florian SEROUSSIMPS is aware of cases where junior doctors have discussed patients on social networking sites, assuming that they would not be identified – but they were exposed and those involved were disciplined.

The Journal of the American Medical Association uncovered many online breaches of patient confidentiality on social networking sites. The study found explicit postings from trainee doctors that revealed private patient information. Most were in blogs, including one on Facebook, containing enough clinical information that a patient could be identified.

Social networking sites blur the boundary between an individual’s public and professional life. Be wary of posting inappropriate material on social media sites, such as photos that may bring your professionalism or that of colleagues into question, even if they are taken in your free time.

However, tight privacy settings can create a false sense of security. Comments about your day-to-day work and the patients you have seen, even if anonymous, still pose a risk, as the information may be identifiable and so may breach confidentiality.

Protect yourself

Follow these tips from Sophos to protect yourself when using social media:

• log out when you move from one terminal to another
• check what levels of privacy you have set up
• enable secure browsing using https. This can be found under the account settings tabs of most social networking sites.
• choose a password with a mixture of upper and lower case letters and other characters, and change it as regularly as is practical.

Things to remember:

• Your ethical and legal duty to protect confidentiality applies equally on the internet.
• Do not accept current or former patients as friends/followers.
• It is inappropriate to post informal, personal or derogatory comments about patients or colleagues on public internet forums.
• Defamation law can apply to any comments posted on the web made in either a personal or professional capacity.
• Ensure that you do not inadvertently breach your contract of employment, by being aware of your local commissioning body or health board’s policy on blogging, etc.
• Be conscious of your online image when posting images on the web and consider how it may impact on your professional standing.
• Doctors and medical students who post online have an ethical obligation to declare any conflicts of interest.

The appetite for social networking can only get bigger, so doctors should take advantage of its many benefits, as long as they are balanced against the risks.

This is a summary, read the full article here. The BMA has also produced useful guidance here.

Top time for Hot Water in 2012?

“Personal profiles on Facebook and other social-networking sites are a trove of inappropriate and embarrassing photographs and discomfiting breaches of confidentiality. You might expect that from your friends and even some colleagues — but what about your doctor?” Time Magazine

This is current news in 2012, but if you look at the date of publication of this time article, it’s September 2009. Although this was published over two years ago, we think medical students are going to be coming under increasing scrutiny as the year unfolds.

It’s happened before, in the UK…

Remember people playing the lying down game? Roll back to Swindon, UK. A number of junior doctors were suspended for what many medical students and doctors considered hijinks: posing for photographs whilst lying down in unusual places. See our example of the latest MRI-PET scanner here:

It’s happening now…

A research paper from 2010 looked at a small group of medical students in Liverpool, UK. Over half had witnessed unprofessional behaviour by their colleagues on social media.

Dr Amy Cunningham, a lecturer from Cardiff University recently highlighted on Twitter and her blog about doctors using slang on social media, e.g. referring to ‘mad-wives’ instead of midwives. For her efforts, both she and the doctors in question were both applauded and criticised by healthcare professionals and different elements of the national press.

Help is at hand…

If things seem a bit blurry and you dont know who to turn to for advice, fear not – as we have compiled a handy list of references:

• From Your Institution – Check if you have guidelines at your University, and follow them!
• From Professional organisations
• From the MPS: The pitfalls of social networking
• From the BMA: Using social media: practical and ethical guidance for doctors and medical students
• From the AMA: Social Media and the Medical Profession: A guide to online professionalism for medical practitioners and medical students.
• Help From Within – We think ‘use your moral compass’ is a great adage. See the moral compass example of one experienced GP below.

Advice from an experienced user of social media

One of our medical professionals says this:

“I use this principle. If I wouldn’t be happy with any of: my mother, friends, work colleagues, peers, nurses, receptionists, patients, friends of patients, children of patients, professional licencing bodies, line manager seeing it, don’t post it. Do not post anything relating to your workplace, patients, or patient care online. If you have a grievance, use formal channels.”

What about anonymity online, protected tweets, protected postings?

“Just be careful. Is it worth risking your professional status over such minutia? The security of these areas is becoming increasing difficult to police. Don’t go there.”

Happy – and safe – tweeting in 2012!

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!

We always enjoy stories about medical students getting up to fun and frolics over the festive period but it seems that an unfortunate incidence at the 9/11 memorial in New York has left one medical student in the US facing jail.

Meredith Graves, 39, from Tennessee apparently had a permit for the gun, a .32 calibre pistol for her home state. On asking a guard where she could check her hand-gun, she was promptly arrested leading to a flurry of comments from the on-line community about the rights and wrongs of being jailed over such actions.

Her mother in law is quoted as saying the following.

Everyone down there carries, and she just forgot. She was being honest, and this is the treatment they give innocent people.

Be careful when approaching an armed medical student?

We’re a little worried about the slightly more serious prospect of being confrunted by an armed medical student at a job interview or on a post-take ward round. It brings a whole new tact to the question “is that fast-slow AV-NRT or slow-fast AV-NRT”. One of Medical Educator’s contributors had the following to say.

It makes a change hearing about students getting into problems with social media. Two thoughts. One: what’s the stupidest thing you have taken to a job interview (a gun would be up there, although could prove useful for some competitive specialities). Two: is jail the right thing. I can’t imagine what my own institutions fitness to practice committee would say about it. But jail?

Note: There is a poll embedded within this post, please visit the site to participate in this post's poll.

Footnote

*We think that most people that claim to know the difference between these forms of atrio-ventricular nodal re-entrant tachycardia are either (1)lying (2)trainee cardiologists (3)deluded.

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?

The more traditional “communication skills” teaching has focused on the doctor–patient relationship, yet communication between colleagues in hospital and primary care settings is equally important.

Photo by Skype NomadMPS’s experience over many years is that some of the biggest mistakes in hospitals are the result of poor communication. Although there are often many factors leading to adverse outcomes, it is undoubtedly the case that poor communication and handover can result in inappropriate prescriptions, incorrect diagnoses and patients lost to follow-up. These have clear potential for patient harm, and an associated impact on the team arising from complaints, claims and disciplinary investigations.

Developing both your teamwork and communication skills at medical school will stand you in good stead as a doctor. The GMC emphasises this in its guidance, Medical Students: Professional Values and Fitness to Practise, stating that: “Medical students need to be able to work effectively with colleagues inside and outside of healthcare in order to deliver a high standard of care and to ensure patient safety.”

Communicating well in a team demands more than merely listening and passing on messages. Doctors must work within their competence, seeking advice and assistance from senior clinical colleagues where appropriate.

On occasion, doctors may need to act to protect patients from potential harm caused by inadequate systems or procedures, or as a result of a colleague’s behaviour, performance or health. MPS recognises that this is never an easy decision. If you need advice on the appropriate action to take, you should usually raise this with your educational supervisor and you can always access expert medicolegal advice via MPS’s helpline.

Survival tips for good communication

• You may feel as if you are at the bottom of a long chain – but in fact you are part of a wide communication network within primary and secondary care, including the voluntary and social sectors. Try to think about your individual role – what information should you convey to assist in protecting the patient’s health?
• As a student, the GMC expects you to demonstrate that you are developing teamwork and leadership skills. Be willing to work as a team and take on appropriate responsibility.
• However, never work outside your competence. If in doubt, always ask.
• If you are concerned about a fellow student, colleague or other health worker, raise your concerns with the appropriate person – this is usually your educational supervisor, consultant or GP trainer.

Well done to those who answered correctly, and comisserations tho those who got caught out… the correct answer to this question was:

g. Guillain Barre Syndrome

See why it was Guillain Barre Syndrome below. Check your hypothesis against the clinical signs:

Remember FVC monitoring in GBS.

Get more free questions here!

One of our testing medical students said the following about the resources:

“They are simple to use, well-structured and take you through a mock clinical case. They throw in a few curveballs just like you get in the OSCE stations”.

Medical students need exposure to cases. These resources provide an easy way for you to test out some of your clinical knowledge in 14 or so different areas. The cases have input from specialties and from a general practice perspective so you get a little internal medicine, a little dermatology, cardiology, paediatrics, pharmacology, endocrinology, surgery…. a little bit of everything!

One of our Medical Specialist contributors commented:

“I examine medical students in OSCE examinations, the last ones I did were October 2011. It’s clear that stress plays a big part in how students can approach OSCE exams, hopefully this provides a little bit of a taster for the sorts of questions you can get in medical final examinations. We hope its good practice, and a free resource like this can only be good news for students.

Find all the resources on the MPS Facebook pages here.

A 44 year old builder presents with weakness over the past 48 hours.

A neurological exam reveals the following (N=normal):

Which of the following is the most likely diagnosis?

a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome

Leave your answers as comments, and we will give you the full professional medical answer in a few days!

Remember, for more MCQs check out our free question bank here.