whatever you dream of begin it…..

whatever you dream of begin it…..

be inspired

W.H. Murray, from the Scottish Himalayan Expedition

“Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness. Concerning all acts of initiative (and creation) there is one elementary truth, the ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, then Providence moves too. All sorts of things occur to help one that would never otherwise have occurred. A whole stream of events issues from the decision, raising in one’s favour all manner of unforeseen incidents and meetings and material assistance, which no man could have dreamed would have come his way. I have learned a deep respect for one of Goethe’s couplets: Whatever you can do, or dream you can, begin it. Boldness has genius, power and magic in it.”

take action today

I find this text deeply inspirational  - I hope you like it too

Dr B

case of the day 4

good afternoon my friends

another clinical collection for your delectation

Word of the day:

Borborygmi - audible bowel sounds (tummy rumbling). Hyperactive bowels sounds may be an indication of hunger or irritable bowel syndrome. One borboygmus, two borborygmi if etymological pedentary pleases you

Tip of the day:

when looking at the legs for pathology, don’t forget to look underneath. Grasp the big toe and gently lift the leg – inspect the back of the calf for veins and ulcers, also the medial aspect of the leg for the long scar of saphenous vein harvesting (bypass surgery). I once palpated a lady’s popliteal fossa and felt my hands disappear into what felt like marmalade as I discovered an ulcer that I’d not looked for (no gloves either…)

long saphenous vein harvest

Case of the day:

a 27 year old fireman comes to see you with a three day history of shortness of breath. This is pleuritic in nature. No cough, no fever. Worse on exercise. No obvious trigger. Soft non tender calves and not flown back from Australia recently. Clear chest on exam. ECG shows nil abnormality and exam is normal . His respiratory rate is 24 and his pulse is 80

You notice that this is a tacchycardia for a young fit man and that his resting respiration should be around 12-16. You correctly suspect a spontaneous pneumothorax which is confirmed in A&E on CXR. As it is less than 2cm when measured it can be managed conservatively with a follow up Xray in a week (see BTS guideline for a more detailed algorithm)

spot the difference

(yeah yeah I know this is a lady pic… and this is a sizeable right sided collapse. Don’t forget in exam to make a show of checking for mediastinal shift by tracheal centrallity and apex position. The mediastinum will of course shift away from a tension pneumothorax and towards a simple one)

Drug of the day:

erythromycin – this is a macrolide antibiotic. It has a broad spectrum of action and is largely used in penicillin allergies – it has a tendancy to cause stomach upset (either diarrhoea or constipation) and is a red tablet usually taken qds (250mg qds is a typical dose). It is an enzyme inhibitor so if taken with warfarin the warfarin won’t be broken down as well and thus the INR can creep up. It is the drug of choice for treatment of whooping cough (pertussis) – decreases infectivity but the cough still goes on for 100 days

Take care of your elf

Dr B

Why be a GP?

Good afternoon my little chickens

db9

Good question (a GP = general practitioner = family practitioner = generalist = jack of all trades doctor master of none)

It is widely acknowledged that the days of the generalist are passing. Is there any place in modern medicine for someone who has a truly general approach?

I’m biased (because I’m paid to provide this kind of service) – so have to declare that self-interest, but feel that primary care physician’s have one of the best medical jobs that exist

actually this is gynaecology

The variety of presentations is glorious and keeps one truly on one’s toes diagnostically and educationally with so many ongoing challenges to keep up with that a day doesn’t go by without my learning something new

Though of course that may simply reflect my rather low baseline!

Today I saw:

1. conjunctivitis
2. chest infection / depression / alcohol misuse / sleep disorder / overdosing of nicotine replacement therapy (one patient)
3. superficial spreading melanoma (possibly) and keratoacanthoma (both on the skin of the one patient)
4. flu-like illness and asthma exacerbation
5. cervicalgia (pain in the neck) – the subjective sensation rather than my objective view of course
6. possible sub-arachnoid haemorrhage
7. flying phobia
8. mesenteric adenitis
9. chest infection
10. apophysitis of peroneus brevis
11. chest infection / asthma flare (another)
12. severe anxiety with knee pain (likely somatisation)
13. UTI with RUQ pain of unknown origin
14. pharyngitis
15. viral cough (3 year old)
16. cradle cap
17. tonsillitis
18. pemphigoid
19. trapezius spasm
20. symptomatic atrial fibrillation
21. low back pain (mechanical)
22. epistaxis (that’s a nose bleed)
23. adverse drug reaction (to lansoprazole - perioral desquamation)
24. gastro-oesophageal reflux disease with a bladder stone recurrent UTI

and that was just my morning

I think it was all rather interesting

Dr B

Case of the day 3

Good morning world

- how are you all doing?

Word of the day:

tachyphylaxis – [G: tachys = speed + phylax = guard]

this is the rapid loss of repsonse to a drug. An example is ephedrine (a sympathomimetic) which loses its response as the noradrenaline becomes depleted from the nerve terminals. Another popular example from the 60’s was psilocybin – hippies couldn’t easily have two trips in a row

Tip of the day:

If the patient is rambling say ‘I’m sorry but I’ve lost my way with that – can I just clarify I’ve understood..’ repeat any of the facts you recall and then get them to give you a more streamlined version. If required rinse and repeat

Case of the day:

20 year old girl with recurrent abdo pains brought on by stress. Has weight loss. Opens bowels 2x per day. Diagnosed as IBS by GP. Mebeverine hydrochloride some help (an antispasmodic, 135mg tds – can be bought over the counter as colofac). She finds it is troubling her at work and at night too. Five years of symptoms

Crohn’s disease is found on biopsies taken at colonoscopy. Transmural fissures seen with skip lesions

She has a long history which is typical with undiagnosed inflammatory bowel disease. She had none of the blood or mucus production and no oral ulcers or very frequent motions as text books tell you that you should find – clinicians are sometimes slow to diagnose these cases but be warned very few present like the books. Nocturnal symptoms are not typical of IBS and should ring a big fat alarm bell

She went onto do well on 5-amino salicylic acid bd once her symptoms were controlled with a 5 day course of prednisolone (40mg each morning)

Drug of the day:

acetazolamide – a carbonic anhydrase inhibitor and works as a diuretic. Used in mountain sickness (prevention) – descent is the best treatment along with steroids if cerebral oedema develops

all the very best

Dr B

case of the day 2

Seasonal greetings mi amigos

A few more nuggets to try and scintillate a few synapses

Word of the day:

volvulus – a twisting (from the same derivation as the word volvo meaning roll and from where we get the word revolve).

Any structure around a pedicle (ovary, testicle, bowel – sigmoid). This usually causes a problem due to kinking of the blood vessels leading to ischaemia which is extremely painful, extremely destructive and needs extremely urgent intervention

Tip of the day:

Turn up ten minutes early to ward rounds – get the latest blood results, have an up to date patient list and make sure the relevent notes are in the trolley. This will save time, ease fraying tempers and make you seem god-like compared to your colleagues. Your day thus goes better and you all get tea and cake for a reward (probably) – overall it’s worth ten minutes of your unpaid time to generate a stress free day (but don’t stay late at the end of the day – you deserve your rest and never get any thanks for that one)

Case of the day:

A delightful 82 year old lady has been deteriorating over the last 4 months becoming increasingly forgetful and prone to midnight naked wanders to the shops. The police have asked that she see her GP as they are concerned for her safety. You question her daughter (collateral history) and discover that she has been incontinent of urine most days though repeated samples sent by the district nurse haven’t yielded any growth. On examination she has a wide based gait but otherwise physical examination is normal. She has a MMSE score of 23/30

You astutely notice she is wet, wobbly and wacky (well demented anyway) and confidently diagnose normal pressure hydrocephalus which is confirmed by large ventricles on the CT and normal opening pressure on the lumbar puncture when the medics see her

Drug of the day:

morphine – this is an (jolly effective) analgesic derived from opium and is thus an opiate (an opioid such as tramadol has similar properties but is synthetic). In liquid form (oramorph) it acts quickly and is used in doses of 5-10mg initally (5 in children) – this equates to 2.5 or 5ml. If used regularly is can cause tolerance (you need a bigger dose to achieve the same effect) and has a withdrawal syndrome. giving the salt morphine sulphate as a tablet has a slow release profile and gives a steady level of pain control throught the day (this is a controlled drug whereas oramorph isn’t). Too big a dose can lead to respiratory depression (a feature accentuated by alcohol of benzodiazepine ingestion). Constipation is the main feature patients complain of and itching can suggest too high a dose. Naloxone is an injectable agent which displaces opiates form their receptor and can be used iv or im (a slower route) in emergency situations (unconscious, respiratory arrest and pin point pupils)

keep well

Dr B

Case of the day

Wotcha gang

I’m trialling a new format-  let me know if you like it

Word of the day:

coracoid process [G: korax = raven + -oid = like]

this means raven’s beak. It it the bit that pokes forwards from the scapula. You can feel it just below the collar bone.

Tip of the day:

Don’t forget to eat. You don’t get too busy to fill a car up with petrol so why treat you’re body the same. In a long shift you’ll work better with a ten minute sit down and a drink and actually end up saving time if you’re busy.

Case of the day:

47 year old man with painful finger for two days. Worsening – no history of injury. Left index finger. He is a right handed accountant with no outside interests.

He has a finger which is red and swollen over the entirety of the distal phalanx. Flexion and extension at this joint is limited and there is pointing over the ulnar border adjacent to the nail

He has a paronychia (this is a cellulitis, usually confined to the distal phalanx – frequently without any prior episodes or history of trauma)

In theory it should be drained. Needle drainage often proves inadequate as the pus tends to be too thick, so incision along the side of the nail in a sweeping incision towards the growing area of the nail is requires after a ring block (local anaesthesia regional block – don’t forget.. no adrenaline!). Pleasingly a lot of these get better with a short course of oral flucloxacillin (500mg qds 5/7) without the recourse to such drastic measures. Oh and do check his BM if he gets lots of skin infections

Drug of the day:

prednisolone - this is a glucocorticoid (cos it raises glucose levels as a stress hormone). Mimics natural glucocorticoids and thus is used to damp down inflammation in rheumatoid joints, decrease brain oedema in cancer and calms down severe asthma. Used in children 2mg per kg (as soluble tablets into an extremely foul tasting pink liquid). In adults that would be 2×70kg = 140 = too much. Adult max dose is around 60mg a day.

Give in the morning as it keeps patients awake. Lasts 24 hours. If given for 5-7 days it doesn’t suppress the patients adrenal axis so doesn’t need tapering off. If long term use watch out for cushingoid side effects of centripetal obesity and diabetes.

If long term don’t forget to cover with bisphosphonates as the bone mineral density is lost in the first few months. Also idiosyncratic reaction of psychotic depression so don’t hand them out like smarties

hugs and kisses

Dr B

enzyme inhibitors

me again!

a brief description of how to memorise that pesky list of enyme inhibitors

enzyme inhibitors can lead to toxicity by stopping the liver from breaking down drugs. When these drugs levels rise all sorts of mayhem can ensue – and that aint no fun at all, so knowing this list will help you save lives (you clever little sausages)

The list was published on my main site but I think you’ll find this more fun

Our memory image starts with a cartoon Dwight D. Eisenhower (5 star general of the US army, 34th US president and one time supreme comander of NATO), see him strutting round his house looking rather pleased with himself admiring the shiny five stars on his jacket. We can imagine peering in through the window at him to see him waving back and mouthing a big friendly hello, grinning from ear to ear he then puts himself in one of his famous trances and meditates ……ommm ommmm (how rude)

only we could have seen in properly to notice that he wasn’t wearing anything below the waist and how he was at the same time abusing lots of silly little cartoon ants, oh how those ants take the abuse and oh my how really hairy he is, thick luxurient hair – just imagine

We see how he stands and turns to find his valet saluting and shouting “sir general sir Eisenhower sir” and handing him a large container brimming with water and hundreds of phone sim cards bobbing about in it. The general sips and sips from that huge container with the sims spilling all around him. Before we know it he is rolling around on the floor giggling away, completely intoxicated and dunk. That funny valet – he’s played another prank on the general and givensolvent. Imagine that – see how they laugh

AODEVICES – hello (allopurinol), omm (omeprazole), ant abuse (antabuse is of course the tradename for disulfiram), hairy (hairythromycin – i mean erythromycin), valet (valproate), Eisenhower (isoniazid), sim (cimetidine), sip (ciprofloxacin), intoxicated (ethanol intoxication), solvent (sulphonamides)

Go on try it with your eyes closed? – how many did you get

Try again – get them all this time?

aortic device

I hope this is useful

Dr B

enzyme inducing drugs

Greetings earthlings

I cordially invite you to join me on a memory adventure

Today we are going to learn how to recall (liver) enzyme inducing drugs (you know, the ones that make your p450 cytochrome oxidase pathway work faster and thus decrease the effectiveness of the oral contracetpive pills and other stuff)

They are (phenytoin, carbamazepine, barbiturates, rifampicin, alcohol and the sulphonylureas) easier to remember than you may think

We will use a few memory devices here

I originally posted on this in list form but you’ll perhaps find this easier

Imagine a PC (that’s an english police constable for those of you not in the UK) in her bra and suitably interesting lingerie. See her leaving the house (hers, yours, your choice) with penniesoverflowing from her heaving bosom and out of that bra. She takes one of the shiny pennies out and pops it into the coin slot of a comedy coin operated toy car which she rides bouncing along to next door whic h turns out to be a barbershop (complete with pole) – you see her go into the shop with its wooden floor and tinkle of the bell as she enters.

imagine

She then spots that cheeky chappy the barber who is standing on the counter triumphantly urinating red urine into one cocktail glass after another. These red overflowing splashing glasses are drunk wearily by a small quiet customer who is bothered by the alcohol putting him of his crossword solving, what a bother to him (in his small spectacles and geeky outfit) he just isn’t getting the word urea despite also the urine around him

PCBRAS are the initial letters. Hence a PC in her bra. Penny (phenytoin), car (carbamazepine), barber (barbiturates), red urine (rifampicin-  turns ALL your secretions red… even those ones!), alcohol (….wait for it…… alcohol) and solver (sulphonylureas)

Close your eyes and try to recount these – you’ll be surprised at how easily it sticks and how recalling the list is more fun than learning medicine really ought to be

Lots of love

Dr B

Haemorrhoids – what a pain in the arse

Right everyone, sit up straight and pay attention. This is an area that is poorly understood. I will now try to shed some light where the sun don’t shine

Your bum is designed to pass poo out. It does this best if it is in well formed turds. Liquid poo comes down the digestive tract (colon) round the S-bend (sigmoid colon) and into the rectum (the straight bit near your bumhole). Here the liquid poo has some of the water reabsorbed so that it becomes a nice putty consistency and can be poo’ed out (defaecation)

Haemorrhoids

The lining of the rectum is well supplied with blood vessels (so that water can be absorbed) and these are formed into small grape like clusters near the lower end. This is called the haemorrhoidal plexus (which is where the name haemorrhoids comes from). The haemorrhoidal plexus of veins can become distended and enlarged (a bit like varicose veins in the legs) and occasionally dangle out of ones tail end. If this occurs, they are usually easily pushed back in with a finger (they can have elastic bands placed around them to make them shrivel up (done in the surgical clinic up a device called a proctoscope). Some surgeon inject them with something to make them shrink (a sclerosant such as phenol)

external haemorrhoid shoud be correctly labelled perianal haematoma

If ones haemorrhoids are enlarged (something that can happen in pregnancy) then you are prone to having a hard bit of poo (like concrete) scrape them – this tends to cause painless bright red rectal bleeding and classically comes out of the bottom just after the poo, and can even leave bright red streaks of blood on the poo.

This is what one looks like up a proctoscope. For grading (I-IV by Banov) check the wikipedia link

this is painless

Perianal haematoma

I will here mention another thing near the bottom called a peri-anal haematoma. This is important mainly because this is what most non-medical people (and a few medical ones) incorrectly call ‘piles’ or ‘haemorrhoids’. Ones anus (the crinkled skin which stretches to allow poo out and then shuts to keep ones pants clean) is a very well designed bit of kit. It needs a good blood supply and indeed gets one. The circular muscle just inside which has the same function is also well supplied with blood. This means that there are plenty of blood vessels around. The downside of this is that on ’straining at stool’ (trying to push a hard poo out) you can burst one of these blood vessels. This results in a blister under the skin right next to your anus. You can see these – they are bluish and around 1cm big. They are very tender to touch when they first form

this is painful

Haemorrhoids are painless (because they come from inside you where there aren’t stretch fibres in the skin covering it) and perianal haematomas are painful (cos they arise from the outside skin – which really doesn’t like being stretched). Another word for haemorrhoids is ‘piles’ (or Chalfont-St-Giles in English cockney rhyming slang)

Piles are painless

When a perianal haematoma shrivels up (a few weeks later – though you can expect the pain to be gone after a few days) it is because the body has reabsorbed the blood. Sometimes the skin has become over-stretched and leave a small skin tag (these may be seen with the aid of a mirror and are of no consequence

Sometimes you get dark blood (or even black like coffee-grounds) out of your bumhole (this is potentially more serious and you should go and see a doctor – it can sometimes be a sign of cancer. Particularly if you have any unexplained weight loss or abnormal tiredness)

Cream for the itching?

Before I leave perianal haematomas alone I need to dispel a few more myths. Creams that you can buy from the chemist won’t help. They won’t go away any quicker (nor will proper haemorrhoids dangling out). These creams claim to stop itch.. well the itch is usually caused by poo. That’s right. Your ring piece has got beautiful crinkled skin and it is very easy to get a few specks of poo left after you wipe. This is much more likely to happen if you have a painful blue grape there as well (perianal haematoma). Poo is painless inside (again, the skin inside is specially designed for this) but very irritant if it is contact with the delicate outside skin

Quite a successful way of cleaning if one is in pain is to use wet-wipes (moist toilet tissues) and to gently wipe till you don’t get any marmite (brown slears). This is cheaper that those creams – and more likely to work now you have a good grasp of the underlying anatomy and medical condition which you may have

No more marmite

Anal fissures (not all they’re cracked up to be)

A quick word on fissures and then we’re done. A fissure is a crack or split in the skin of your anus (bumhole). These can be exquisitely tender and typically cause pain on pooing. Also some bright red blood may be seen on the toilet tissue. Most of these get better with good cleaning (see above) as this removes the irritant material with can perpetuate the fissure. Occasionally you may need to consult a doctor (who can prescribe medication – GTN or glyceryl trinitrate ointment, which can be very effective)

The last word is just to mention some detail about the above conditions for those who like to put things up in the other direction (fingers, willies, vibrators and so forth). Haemorrhoids won’t be worsened (though if bleeding occurs you may wish to be a trifle more gentle), perianal haematomas – i recommend waiting until they aren’t painful, these also won’t be worsened. Anal fissures may be worsened – so I would suggest waiting until the fissure is completely healed. Anal bruising is painful and looks like a generalised red/blue discolouration which tends to be painful – in which case I recommend lots more lubrication, more gentleness or avoid the bum

Keep well

dr B

Acne rosacea

Alright y’all

 

Rashes on the face come in several patterns. These can at first appear confusing. With a little understanding we will get you diagnosing people on the subway, weddings and other gregarious occasions

acne rosacea zones

Today we will look at acne rosacea. This diagnosis is one to get right because with the right treatment much improvement may be had – though with the wrong one the patient can get worse, and primum non nocere (as we docs like to say)

Famous faces

Sir Alex Ferguson

Famous folks who have this skin condition include Sir Alex ‘the hairdryer’ Ferguson (coach of Manchester Utd football club and often red faced in team talks and when discussing Chelsea). Also President Bill Clinton (I’m sure we can picture him maybe a little red-faced?)

President Bill Clinton

Sebaceous glands and blood vessels

It is not clear whether the pathology is entirely due to inappropriate response of underlying vessels in the skin. Acne rosacea widely varies in its severity and there are a few different sub-types recognised. Facial flushing is particularly associated with one type and rhinophyma is associated with another. Erythema (redness) and telangiectasia (small dilated vessels) may be found

rhinophyma - bullbous nose

Acne rosacea tends to occur later on in life. More common in ladies but more severe in men. It can be associated with excess alcohol consumption though this is not causal. The flushing associated with acne rosacea can be precipitated by sunlight and the rash may get worse with minor irritants. Those irritants can include steroid creams, benzoyl peroxide or isotretinoin (unfortunately these are often prescribed for acne vulgaris and seborrheic dermatitis for which this can be mistaken). It should go without saying that chemical peels don’t help, but aggravate acne rosacea

Stress and changes in temperature are often triggers for the flushing as are some foods (eg. spicy) and caffeine

Interestingly there is some research which shows that patients with acne rosacea are more likely to have small intestinal bacterial overgrowth and that eradication of this by a long course of antibiotics is likely to cause a resolution of the symptoms

 

Mistaken identity

Acne vulgaris tends to be more pustular and involve the neck, chest and back whereas seborrheic dermatitis tends to involve the scalp, hairline and ears more. A good rule of thumb is to think of acne rosacea as solely a facial condition

 

 

seborrheic dermatitis - involving the hairline

Note that lupus pernio (sarcoidosis of the nose) may be mistaken for rhinophyma

Treatment

The tetracyclines by mouth (eg. oxytetracycline, doxycycline) may be effective as may metronidazole (an imidazole) cream topically. If the eyelids are involved (and they are in about half of cases), then lid hygiene (regular cleaning with a baby shampoo and moisturising) is useful

For resistant cases, dermatologist specialist management is needed (indeed about 1% of all a dermatologists caseload are those with acne rosacea)

 

Finally acne rosacea is a chronic condition and most cases need some form of treatment (even if only trigger avoidance) for a lot of their lives

 

Keep well my lovelies

 

Dr B