The Humble Rounds

Special Thanks to everyone who showed up for the humble rounds.

(Click to Enlarge)

The idea is simple. Get together, discuss and share knowledge. To stimulate thought, each person starts off with a presenting complaint. The audience then plays doctors, going through the history, examination, investigations, and differentials.

Learning tangentially; in the context of something you are engaged in; is the most effective way to learn.

A scribe records the proceeds (cases and discussion). The minutes are then emailed out. This allows everyone to refresh their memory of the cases - a simple step that takes less than 5 minutes, yet solidifies knowledge in one's working memory.

Feedback has been very positive. Two rounds have already been done.

The next round will be held on Tuesday 22/5/12.

22/f w pneumonia after a really bad cough

Three weeks ago I had a really really bad cough. So bad in fact that a few days after it started I noticed a soreness in my left rib. It's just over that spot really and it hurts when I yawn or take a deep breath. Prior to that I had a bit of a cold but it did not concern me enough to visit my GP. My mum who's a nurse describes it as the worst cough she has ever seen. The cough was so bad that I ended up vomiting. My GP had put me on Amoxycillin/Clavalunate but my symptoms were not improving much after a week. He also prescribed me some Paracetamol/Codeine (1g/30mg QID) for pain that I have been taking regularly but my pain was still not very well under control. I got chills/rigors just as my course of antibiotics was finishing. The cough had settled slightly by then but the pain was unbearable especially when lying down and taking deep breaths/coughing. I literally couldnt lie down and sleep sitting up on a chair.  Yesterday I started to get a little short of breath so I came to emergency. I was started on roxithromycin and given a shot of ceftriaxone. I've been feeling much better since. This was a two days ago, and im coming in today for my daily shot of ceftriaxone.

*for sake of brevity, abx names have been included in the quote.

Hx: Otherwise well nil issues not on meds.

Ix: CRP 5.1 WCC17.5(14.2) w mature neutrophilia. GGT328 ALT 207 AST 128 ALP 147. CXR n. CT Chest small localized posterior R-LL pneumonia. Sputum culture from ED nad.

O/E: Chest clear. Nil SOB. localized pain in chest when coughing/yawning. stable afebrile.

What was the likely missed diagnosis?

Corticosteroids, 5-20-750

5mg of Prednisolone = 20mg Hydrocortisone = 750mg Dexamethasone

Axioms: The body produces around 20mg cortisone daily. More than 20mg hydrocortisone causes adrenal suppression. The synthetic ones produce less suppression. Above the physiologic level (bolded above), side effects rise dramatically.

Signs: In all patients consider that signs of infection may be suppressed. Cushingoid appearance: moon face, hirsutism, buffalo hump, flushing, increased bruising, striae, acne.

Why Corticosteroids Are Bad For You:

• Osteoporosis
• Muscle wasting
• Skin thinning
• Hyperglycaemia
• Adrenal atrophy - via negative feedback on the hypothalamic-pituitary-adrenal axis.
• Masked infections - anti-inflammatory, analgesic and antipyretic
• Menstrual irregularities
• Hypercoaguability - embolism

FAQ:

Prednisolone is not Prednisone. The latter requires hepatic metabolism to be converted into its active form.

Above the physiologic dose, many patients report feeling sick and unwell.

Updated 15/4/12

50/m w severe lower abdo pain

9/10 abdomen pain when I called the ambulance an hour ago. It's now probably 6/10. It's always there and spikes up every fifteen minutes to a point where it's unbearable. I've been getting these pains yearly in my lower abdomen for the past six years. It all started 12 years ago when I had part 4 feet of my terminal ileum and part of my caecum removed after a severe flare up of Crohn's disease. It was fine for the few years after the operation but the pain started 6 years later. Being the holidays and all, I had a really big meal two nights ago with my family. It started to really hurt past midnight, but was bearable until 12 hours later when it really got painful.

Further Hx: Last bowel motion 12/24 ago soft/brown/formed. Severe nausea and vomiting, unable to tolerate solids and only taking small sips of clear liquids. Otherwise well, not on any medications/steroids. No current medical issues.

O/E: Stable afebrile. Rebound and guarding in the lower abdomen with maximum severity in the RIF. Bowel sounds present. Nil renal angle tenderness. Nil masses. Abdomen looks distended but patient says it's normal for him.

Ix: FBE U&E n. CRP 8. AXR shows feacal loading. Otherwise nad erect and supine. No free gas below the diaphragam.

Rebound and guarding are very clinically important signs. The surgical registrar was called.

What is the next step in this patient's management?

80/f w lethargy and dysuria

I've been feeling very tired recently. Not all the time but most days. I've had this crampy pain in my lower abdomen and it burns when I urinate. I've been seeing my GP for about 15 years for this recurring problem and he usually gives me co-trimoxazole for my urine and it goes away. This time it has not. He put me on another antibiotic (cephalexin) as well but it did not help.

Further Hx: Typical urinary symptoms; frequeny, dysuria++ and nocturia. Nil significant medical history. Well controlled hypertension and longstanding LL oedema. Has been incontinent of urine post uterine prolapse surgery 10 years ago.

Ix: Her last set of bloods and urine tests were done 2/52 ago. They showed:

• WCC 9.0 (5.4)
• Urea/Creatininie n.
• Urine MCS: Leuks 60 (<5). Erythrocytes 150 (<5). Gram + cocci but likely contaminated.

Most women will get a UTI in their lifetime, so this is really common bog standard medicine.


What more would you like to know? What would you look for on examination?

Approach to Transient Ischaemic Attacks

Axioms: A TIA is like a stroke that spontaneously resolves. It is not a syncopal episode (LOC is atypical!) and typically involves focal neurology (unilateral weakness and speech disturbance). It is very significant because of a high likelihood of an impending stroke.

Do you know how to?
1) rule out mimics
2) assess severity
3) formulate plan based on severity.

75/f w syncopal episode and abdominal pain

I was in the toilet this morning having a poo when I felt light headed and collapsed just as I was sitting on the toilet bowl. My husband who walked in shortly after said I was on the floor for about 2 minutes. The husband adds: it's like she fell on her buy while trying to sit on the toilet.

Further Hx: Pt states that she has had "dozens of similar episodes in the past" that typically occurred when she was "startled" or "shocked" or emotionally distressed. She gets a bit nauseous as a prodrome and sits down in anticipation. Pt notes that she is currently in dispute with her husband over some domestic issues and has not been sleeping well. The pt does not have a clear recollection of the event since loosing consciousness. Her husband states that she was less responsive than usual for about a minute after coming to her. She does not have a history of dementia or delirium. Denies urinary symptoms. Denies changes in bowel habits.

Medical Records: A half hour search dug up the following details - Past EEGs, ECGs and investigations have all been n.

Ix: All bloods (FBE, U&E, CMP, LFT, CRP, Amylase/Lipase), including cardiac enzymes and inflammatory markers came back normal. ECG n. FWT n.

O/E: Pt looks well but feeling a bit nauseous and holding on to a vomit bag. GCS 15 communicative. Denies pain anywhere. Nil cspine/thoracic midline tenderness. Clears NEXUS. No bruises/bumps/sore spots on her head.


Everything checks out. Sounds like a simple syncopal episode (?vasovagal). We could not get in touch with her GP as it was after-hours. The patient is stable and comfortable. I think she is suitable for discharge and run her quickly by the senior officer.


What Have I Missed?

50/f w haematemesis

I vomited blood last night after waking up around 2am feeling nauseous. It then settled for awhile and I had a second vomit about half an hour later. This time there were sesame seed sized black bits in my vomit. 

Focused Hx: Did not wretch before vomiting. Denies abdo pain. Denies urinary (freq, noct, dys) sx, constipation/diarrhoea, Otherwise well nil meds nil medical hx.

O/E: Dry membranes, BP 100/65, HR 75. Afebrile. Abdo tender on deep palp of LLQ and L renal angle otherwise SNT bowel sounds present, no organomegaly. FWT trace blood nil leuks nil nitrates.

Ix: FBE U&E CRP LFT Amylase/Lipase normal. AXR (erect/supine) mild fecal loading otherwise n.

She looks a bit dry so you start her on 4/24 1000ml N. Along with this 40mg Esomeprazole is given as well.

The investigations came back and you are just about to discharge the patient with an outpatient gastroscopy referral when the nurse calls you out:

ATSP: pt has a BP of 90/59

You quickly examine the patient. Her ex findings are the same as before. GCS 15 alert and communicative. The bag is nearlly empty so she has been transfused roughly 800ml in the past three hours.

What would you do next?

20/f w recurrent tonsillitis

It started with a sore throat, fever and chills. My GP started me on oral abx but I found it increasingly difficult to swallow. I was admitted for a day in hospital for iv abx and steroids to bring down the swelling. It's getting better now. Thank goodness it's my first time I've had to be admitted to hospital for tonsillitis.

Further Hx: Pt has completed 7/7 2g Cephazolin iv. Noted allergies to cetirimide and penicillin (rash).

O/E: Mildly sore on R side of throat. A bit of pus is visible on the posterior aspect of the tonsils. The tonsils are enlarged bilaterally and symmetrically but not erythematous.

Plan: Discharge the patient home on oral abx.


What antibiotics would be suitable? More importantly, what's missing from the plan?

45/f waking up at night feeling SOB, 'choking'

I've been waking up feeling like im choking for the past 2/52. Had a cold the week prior to that. It's pretty bad, I wake up and cough and cough and cough until I feel nauseous. I have vomited a few times because of that.

Further Hx: Clear sputum. Denies chills/rigors/wheeze/sweats. Sleeps on 3 pillows. Denies increasing SOBOE. No travel hx. Mild LOW but assoc dieting. Otherwise well no medical history no meds.

Ix: FBE/U&E/CRP normal. CXR clear.

O/E: Stable afebrile. Lying comfortably. Chest clear no added sounds. Pt feels "well" otherwise. Throat looks clear.

What examination is missing? Likely dx?

80/m w painful unilateral knee

Been having increasing pain in my L knee all night until it became unbearable. Can no longer weight bear on that side and it's really sore to touch here (pointing at medial aspect of knee). It came on all of a sudden. Hadnt bumped it or anything.

Hx: Gout on Allopurinol, IHD, CRF (eGFR in the 20s), OA w reduced joint space in both knees.

O/E: (L knee) No obvious swelling, erythema, or deformity noted. Has gouty tophi on hands. Otherwise stable,  afebrile.

Ix: WCC 13 (10) CRP 2.1 Urate 42 (n<20), ESR 52 (n<20), eGFR 18, Urea 18, Cr 292.

Does this patient need a joint MRI and aspirate?

80yo w sudden pain in R leg

It was like a sharp pain from my left knee downwards. My whole lower leg just hurt and was very sore to touch. I also noticed it was alot cooler than the other leg. It got worse over minutes and became really unbearable which was why i called the ambulance.

Hx
Longstanding AF but not on warfarin due to allergy (pruritic rash).
Known peripheral vascular disease w bilateral femoral grafts 2 years ago.

O/E
pain resolving spontaneously, but it is noted that pt had 5mg of morphine 2/24 prior.
pedal pulses strong and equal bilat.
both feet are equally warm.
both calves are symmetrical in size and non-tender.

Progress:
- A vascular registrar was consulted and an urgent doppler ultrasound was ordered which showed monophasic flow from the mid femur onwards.
- Is there need for an urgent embolectomy/angioplasty?

Welcome To Bite Sized Medicine

Using this site is simple. Visualize the scenario, imagine yourself being responsible for making a decision, and learn tangentially from the real-life case.

Medicine can be really overwhelming sometimes. Thankfully, it makes sense (well, mostly) and alot of things can be learnt relatively easily. IMO, the limiting factor in learning medicine (or CME) is time. It takes time to integrate mental processes into working memory. Put simply, practical knowledge takes time to absorb. Books tend to overwhelm/inundate the reader with too many facts and verbal overshadowing.

This blog takes a different approach to learning medicine. It features the following:

1. Emphasis on keeping it real. Only real life scenarios are used.
2. Small learning points in each scenario that could be easily integrated into your working memory

Difficulty is measured NOT by how difficult a learning point is to understand. It is measured by how intuitive the post will be to the reader. Many third year medical students could probably narrate ECG changes seen during an acute myocardial infarct; but few would be able to integrate the principles of managing an infarct that easily.

• Level 1; 3rd year medical students will find it easy to integrate these concepts. Also the basic stuff you just need to memorize and take to heart.
• Level 2; Bog standard medical practice points. Most doctors should easily visualize and understand this.
• Level 3; Judgement calls made by senior medical officers.
• Level 4; Judgment calls made by consultants. 

Specialty labels are given based on what specialists were consulted in order to make judgment calls. If a particular case required a call to the renal physician, it will be labelled as a Nephrology case. If it also required an O&G consult then it also be labelled as such (r Nephrology, r OnG). I've decided to label things this way to prevent confusion as a simple pneumonia would qualify under Pneumology and Infectious Diseases. Cases that did not receive any specialty consult will be labelled under General Medicine unless they are suitably labelled as Emergencies.