2011 in review

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 17,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 6 sold-out performances for that many people to see it.

Click here to see the complete report.

Posted in Uncategorized | Leave a comment

Constipation

Constipation

 

The best method of cure is prevention

Though if you’re in the unfortunate position of having a back-log this is the best method that I’ve found for clearing it (it works in nearly everyone in 1-3 days).

 ___________________________

Three things: Standard advice, macrogol and suppositories.

 

Standard measures are: enough to eat (to give it a push through), enough to drink (plenty of water or clear liquids) and enough exercise (physical exercise encourages a good bowel action).

 

On top of this, using some medicines to help can work wonders.

 

Macrogol (also known as laxido). An unpleasant tasting powder. Make up with water or similar.

To clear:

Day 1 – 2 sachets, twice a day

Day 2 – 3 sachets, twice a day

Day 3 – 4 sachets, twice a day

Day 4 – 4 sachets, twice a day (most people don’t get to day four)

 

To keep clear: half a sachet once a day (or one sachet once a day, or half a sachet every other day. People vary with how much they will need).

 

Suppositories

I recommend glycerol. They can be prescribed or bought over-the-counter.

They help lubricate the poo, so it feels less like concrete and they help provide gentle irritation to the lower rectum which encourages a really efficient bowel movement.

 

Take a book or something to read into the lavatory (because when it works, you don’t want to have to run the length of the house).

Take the plastic wrapper off (otherwise they are scratchy and don’t work).

There are self lubricating – so hold the bullet (any way up) and wet the end under a tap.

Push it into the bottom (if it doesn’t fire across the room it is probably in far enough). A ‘rule of thumb’ is to push it into the first knuckle.

Then hold onto it for twenty minutes (to give it enough time to work and provide optimum irritation).

 

Then have a pleasing, dramatic bowel action. Repeat as needed. Most back-logs take about three really big actions to clear. If you are prone to them – think about what medicines you are taking, what your diet / fluid intake is like and consider talking to your doctor.

 

 

Dr Peter Windross, November 2011

 

Posted in medical education | Tagged , , , , | Leave a comment

Raynaud’s phoenomenon, Raynaud’s disease, Raynaud’s syndrome

Hi Kitty cats

The phoenomenon is the description of the fingers going through the red,white and blue colour changes (named after French physician Maurice Raynaud (1834–1881) – who described this)

tricoleur

french flag

 

Raynaud’s syndrome, or “Secondary Raynaud’s”, occurs secondary to a wide variety of other conditions. Remember this because secondary and syndrome both begin with an ‘S’.

Raynaud’s disease is described as an allergy to the cold (not accurate but easy to remember) – disease….don’t know of any underlying cause

It is the “R” in the CREST syndrome acronym (Calcinosis, Raynaud’s, Esophagitis, Sclerodactyly, Telangiectasia) – this syndrome thought to be a limited version of Scleroderma which can produce a mouth which looks a little like a cat’s bottom

Coffman’s criteria for the diagnosis of primary Raynaud’s disease

  • Intermittent vasospastic attacks (pallor, cyanosis and erythema) – precipitated by cold or emotional stimuli
  • Symmetrical involvement of hands, fingers (feet and toes too, occasionally penis!)
  • More than 2 years of symptoms
  • No necrosis or skin changes
  • Absence of underlying vessel disease
  • Normal ESR, ANA, anti-centromere and anti-Scl 70 antibodies

Raynaud’s phenomenon

File:Raynaud's Syndrome.jpg

Raynaud's

 

In Raynaud‘s syndrome it is important to establish the cause (here are some if the many aetiological factors):

  • Drugs, poisons, toxins (such as heavy metals like lead)
  • Peripheral vascular disease
  • Trauma
  • Underlying collagen vascular disorder
  • Cervical rib
  • Lung tumour

Asymmetrical involvement and secondary skin change on examination are suggestive of secondary Raynaud’s syndrome.

Investigations are: FBC, ESR, ANA, ENA, anti-centromere antibodies and anti-Scl 70 antibodies

+ chest X-ray to exclude a cause in the lung apex (causing compression of the subclavian artery on it’s way into the arm)

Hope that was interesting

Dr B

Posted in learning medicine, medical education, medicine finals, medicine revision, MRCGP, USMLE | Tagged , , , | 1 Comment

Putting hyperlinks in your comments

Good morning world, how’s it going so far?

 

This is from the splendid post

Are you well-versed in comment etiquette?

(well written, succinct set of easy to follow rules and guidelines)

Bonus trick: Turn text into links with HTML by using the following code:

1 <a href="link">text</a>

For example,

1 <a href="http://wordpress.com">My favorite blogging platform</a>

 

I rather liked that one. I’ll leave with one more quote.

Rules are there to be followed by those not smart enough to use them as guidelines

Peter Windross, 2011

 

Have a great day

 

Dr B

 

 

Posted in have a better day | Tagged , , | Leave a comment

Migraine – half a head

Hello

Today’s condition is migraine. This is a headache which affects half your head (hemi-craine), pronounced with a heavy French accent

They are distinct from cluster headaches (which also are unilateral)

The information here is largely taken from the evidence based Scottish intercollegiate guidelines (SIGN) 2008

Migraine

____________________________________________________________

Characteristics of migraine

  • Episodic
  • Cause disability
  • Unilateral
  • Pulsating
  • Builds up over minutes to hours
  • Moderate to severe
  • Associated with nausea and vomiting / sensitivity to light / sensitivity to sound
  • Aggravated by routine physical activity
  • Typical aura (present in 15-33% 1/6 to 1/3)
  • Sensitivity to light between attacks
  • Positive family history of migraine

So they feel like a hangover, but are one sided and can have a positive family history

The rapid onset is also a feature of thunderclap headache (associated with various different intracranial bleeds) which is a red-flag feature. It is worth learning the red-flags

Helpfully the SIGN guidance says that:

“Patients who present with a pattern of recurrent episodes of sever disabling headache associated with nausea and sensitivity to light, and who have a normal neurological examination, should be considered to have migraine”

________________________________

Investigations for migraine?

If they have a normal neuro exam, a typical history and no red-flags then further investigation is not required. So….. No

_____________________________________________

Acute treatment

Acute treatment is tailored to the individual patient:

  1. Avoid opiates (risk of medication overuse headache) – link to the PIL from patient.co.uk
  2. Aspirin 900mg or ibuprofen 400mg is recommended for all severities of migraine
  3. Paracetamol 1g if for mild to moderate ones
  4. If the simple analgesics don’t work then oral triptans are recommended (almotrimptan 12.5mg, eletriptan 40-80mg or riazatriptan 10mg are the preferred ones)
  5. If one triptan doesn’t work – then try another
  6. Take the triptans ASAP at the headache phase of the attack
  7. Prolonged recurrent attacks may respond to the combination of sumatriptan 50-100mg and naproxen 500mg
  8. Anti-emetics (by mouth or bum) can be used

Prophylaxis of migraine

Prophylaxis (this can halve the severity and frequency of episodes)

There are a whole bunch of these (beta blockers, anti-epileptics and TCADs)

  1. Propranolol (80-240mg) daily is first line
  2. Topiramate (an anti-epileptic) can work
  3. Sodium valproate 800-1500mg a day can work too as can gabapentin (1200 – 2400mg) daily
  4. The tricyclic anti-depressant amitriptyline can be used (25-150mg a day), if this doesn’t work then venlafaxine 75-150mg a day)
  5. Perhaps unsurprisingly stress management and acupuncture both has a supportive evidence base in their role in prophylaxis (make of that what you will)

 

_______________________________________________

Migraine and the combined oral contraceptive pill (COCP)

End note: if  a patient gets a headache with an aura they must have their combined oral contraceptive pill stopped (COCP) – the one with oestrogen in it

This is because there is an unacceptably high risk of stroke (which can of course be fatal). This makes them an UKMEC 4 (and we know that we can only really prescribe in situations of UKMEC 1 or 2) – this guidance is from the Faculty of Sexual and Reproductive Health of the Royal College of Obstetricians and Gynaecologists (RCOG)

That’ll do for now…… I’m getting a headache

BFN

Dr B

(check out my pages on headache – history and examinationheadache – red flags and the cluster headache page)

Posted in learning medicine, medical education, medicine finals, medicine revision, MRCGP, MRCP, USMLE | Tagged , , , , , , , , , , , , | 3 Comments

Cluster headache

Good afternoon guys

Today’s case is cluster headache – these are headaches (one sided) which happen again and again and again (then disappear for a while) and then come back in another cluster

Cluster Headache


trigeminal divisions

green, red or yellow

 

Cluster headaches are the commonest form of trigeminal autonomic cephalgias (TACs).

Unilateral pain in the distribution of the trigeminal nerve

Pain is always unilateral in cluster headaches

Same sided autonomic features:

  • Conjunctival injection and/or lacrimation
  • Miosis and/or ptosis
  • Eye lid oedema
  • Nasal congestion and/or rhinorrhoea
  • Forehead/facial sweating.

Agitation is common

________________________________________

Treatment:

  • refer
  • sumatriptan s/c (6mg) is first line treatment
  • nasal sumatriptan or zolmitriptan second line
  • verapamil 240-960mg is recommended for prophylaxis
  • oxygen and melatonin have less evidence

Done

ciao

Dr B

(check out my pages on headache – history and examination, headache – red flags and the migraine one)

Posted in learning medicine, medical education, medicine finals, medicine revision, MRCGP, MRCP, USMLE | Tagged , , , , , , , , , , , , , | 3 Comments

Headache – history and examination

Hi world

A little piece on how to approach headaches

Please also take a look at the red flags not to miss and a look at cluster headaches and the migraine review

As with all things in medicine – history followed by the examination (then investigations – simple then special, like CT)

Now look here, Doctor ? Years of total immersion in medicine count for nothing when confronted by the expert patient

my head hurts (so does mine)

 

_______________________________________

History


  • Timing
  • Quality of pain (SOCRATES etc)
  • Triggers and relieving features
  • Family history
  • What are they like in between episodes?

The point of the history is to find out everything there is to know about the headache. The clues you look for are those features which will help you determine the most likely underlying cause. Migraine, cluster headache, sub-arachnoid haemorrhage, chronic subdural, tension like headache, etc. all have characteristic qualities which you can bring out in the history. Sir William Osler said…..

“Listen to your patient, he is telling you the diagnosis”

______________________________________

Examination


  • Cranial nerves (O O O)
  • fundoscopy
  • BP
  • neck movements
  • muscle tender spots (trigger points)
File:Fundal photograph showing severe papilloedema in the right eye.jpg

papilloedema

 

Cranial nerves (learn them and their examination, get it slick in 3 minutes – it’s an afternoon well spent which will stand you in good stead throughout your career – and you’ll look cleverer than the students around you :) )

Fundoscopy to look for papilloedema, severe hypertensive changes or clues like diabetic retinopathy

BP – malignant hypertension is important and can be missed

Pain in the neck – can be the joints (arthritic), the discs (can prolapse and press on both the spinal cord and nerve roots) and the muscles (probably the commonest cause of headache is tension held in the occipital insertion of trapezius causing pains which radiate over the top of the head – better posture, less stress, a heat pack and a good massage from a lovely therapist are the best cures)

__________________________________

Ok, those are the salient features

TTFN

Dr B

Posted in learning medicine, medical education, medicine finals, medicine revision, MRCGP, MRCP, USMLE | Tagged , , , , , , , , , , , , , , | 3 Comments

Headaches – red flags

Hi y’all

Today is headache day. Here are a few pointers on how to approach a headache. Avoidance is probably best

But lest the reading in your favourite neurological tome be too headache-o-genic (I’ll admit I made that word up) then here is a brief guide…

It is based on the best evidence I could find:

Headaches – SIGN guidance 2008

______________________________________________.

Definition of headache


Primary: no underlying pathology

(migraine, tension headaches, cluster headaches)

Secondary: underlying pathology

(neoplasms, drug induced, infection)

Chronic: more the 15 days a month for more than 3 months

_____________________________

redflags Top Red Flags for Homebuyers

Red flags

The red flags are often talked about. These are what you spot which makes you think (or should do): I want this patient to see someone -else / -cleverer than / -a long way from here

(in case they -die / -sue / -don’t get better / -get better before I can share this fascinating case and an opportunity to teach my colleagues and demonstrate my superior clinical acumen…. maybe)


  • New onset or change in headache in patients over 50
  • Thunderclap headaches (rapid time to severe, 0-60 in seconds to five minutes – as fast as a Ferrari)
  • Focal neurological symptoms (eg. limb weakness, aura <5mins or >1hr).
  • Non-focal neurological symptoms (eg. cognitive disturbance).
  • Change in headache frequency, characteristics or associated symptoms.
  • Abnormal neurological examination
  • Headache that changes with posture.
  • Headache waking the patient (though migraine is the commonest cause of this)
  • Precipitated by exertion or straining (valsalva manoeuvre – coughing, laughing, have a poo).
  • Patients with risk factors for clotting and thus cerebral venous sinus thrombosis (hypercoaguable states like being pregnant or cancer).
  • Jaw claudication or visual disturbance.
  • Neck stiffness.
  • Fever.
  • New onset headache in a patient with a dodgy immune system (HIV or cancer)

There are fourteen of those and they are fairly obvious if you uncover them. They are all meant to ring an alarm bell. Until you learn them (which will probably take many many patient histories of practice) – simply print off the list as a checklist and use with the patient – impress them with your resourcefulness (they won’t know it because you like me get brain block sometime – don’t worry about this, it is a common phoenomenon amongst budding doctors)

That’s enough for now

Take care

Dr B

(check out my pages on headache – history and examination, cluster headaches and the migraine one)

Posted in learning medicine, medical education, medicine finals, medicine revision, MRCGP, MRCP, USMLE | Tagged , , , , , , , , , , , | 3 Comments

Getting cross

Hello world

Today I want to have a little look at getting cross

I’ve noticed that when I get cross I can get cross at the world in general, the particular circumstances of why the universe is against me today, other people, animals and inanimate objects

Nothing unusual so far I hope

Animals and other people: my girlfriend get cross at the cats for bringing their muddy paws in and walking over the (well chosen I’ll admit) cream sofa – my response is to tease her and say they’re behaving like ‘animals

They are just that: animals, in the same way children are childish and stupid people in your way are just that (not evil, just stupid). It’s not their fault

Ragdoll

muddy paws

 

Few people try to make to angry / sad / frustrated – most are just trying to do the best they can with what they’ve got (mental, physical and emotional resources) – it’s not their fault if they can’t see the world your way, you actually appear the same way to them – so it’s hardly surprising if occasionally we butt heads with people we meet. The trick is to realise that that is all that it is and the world would be a bit weird if it and all the people in it conformed to your every whim anyway

The universe is against me: is it? really?

It may seem like that and that is a good time to stop, take a deep breath and realise that to quote the Baz Luhrman song (wear sunscreen)

Your choices are half chance.. and so are everyone elses

The world turns, events happen and none of these things are conspiring against you (I promise). We have pretty much free choice in most things we do and in how we choose to think moment on moment. Smile, it’s a good start.

Inanimate objects: when these are conspiring against you

Occasionally things wink in and out of existence (like car keys and mobile phones) – that was a theory my 80 year old grandmother claimed (way before our understanding of the ten dimensional universe we currently occupy was popularised by string theory). It is the only explanation for why you are looking for something and you find it in somewhere where you’ve already checked.

My favourite is when I’m running late for work and find my toothbrush in my hand despite having spent valuable minute searching in vane for the bristly plastic scrubbing device.

File:Toothbrush x3 20050716 002.jpg

trans-dimensional mischief

 

The other theory is that is says more about your state of mind that you are blaming other things (objects are clearly not at fault) – I find it interesting that we can apply this to other people too. If someone else is clearly at fault try thinking of them as a malevolent toothbrush switching dimensions just to irk you – and consider that it may be me or how I am today which is causing this perceived friction. It makes me smile more and be a little more generous in spirit. I rarely regret that – it is often extremely helpful

Try it – go on :)

All the best

Dr B

Posted in have a better day | Tagged , , , , , , , , | Leave a comment

Improve you mood

Hi Guys

Today I will offer you something that was shared on a website about moods.

I’m paraphrasing and can but bow to the cleverer offerings of Michael Neill and his genius catalyst stuff and recommend his solutions cafe as well worth investigating

This bit pertains to the weather of what happens in our lives each day

My take is that when we start out in life we are beholden to the prevailing weather (if it’s raining we :( and if it’s sunny we :)

Maturing we are able to produce our own weather – we can generate from within us that which soothes our soul and can (on a good day at least) project this and share with our fellow humans

Weather is all very well but whether is bothers you is all a case of perspective, to take the over view the meta-picture is to see things from the point of view of the sky

The difference between weather and the sky is that if were we to transcend the meteorological phoenomena and issues we are able to see the world from the point of view of the sky (stratosphere and beyond) at which point we see weather systems moving and occurring. We see them as interesting and pretty but they just don’t really get in the way of your day or what you’re up to

Which is nice

File:Anvil shaped cumulus panorama edit crop.jpg

the meta view

 

Have a go (it’s only a mental exercise after all)

:)

Ciao

Dr B

Posted in have a better day | Tagged , , , , | Leave a comment