Wardround 23ix6

This week’s theme had been disorders which can mimic anxiety/panic attacks. We heard about phaeochromocytoma in an excellent talk from VJ Thyrotoxicosis, SVT, Hypoxia, prescription drugs and substances of abuse. My prize for the week goes to AC since he specifically compared the rates of symptoms in panic with the same symptoms in SVT. I would like to re-iterate my maxim that panic attacks do not exist in medical in-patients (pre-test probability low). Though the features of a panic attack (as per DSM IV) may well be present you should look hard for an alternative diagnosis. Be especially wary of findings which are not explained by panic alone.

The discussion paper was Does This Patient With Headache Have a Migraine or Need Neuroimaging? Michael E. Detsky et al JAMA. 2006;296:1274-1283. The conclusion of which was "The presence of 4 simple historical features can accurately diagnose migraine. Several individual clinical features were found to be associated with a significant intracranial abnormality, and patients with these features should undergo neuroimaging... The features are summarized by the mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling. If 4 of the 5 criteria are met, the likelihood ratio... for definite or possible migraine is 24."

In next week's two minute tutorials we will address occupational diseases:
Respiratory (VJ)
Neurological (AC)
GI/GU (s)
Musculoskeletal (CC)
Skin (MJM)
(and infections GAJ?)

Two minutes only, keep it concise and precise; quote your sources.

For the 29th I would like you to read and consider Apology in Medical Practice: An Emerging Clinical Skill. Aaron Lazare. JAMA. 2006;296:1401-1404.
Get the full text via library/elibrary.

Interesting topics
Acute sarcoidosis

MJM

Wardround 15ix6

The theme for this week was Venous thromboembolism. We heard from CC about the epidemiology of VTE (extrememly important given the need for pre-test probability assessments prior to lab testing); from VJ regarding investigation (the synthesis of clinical assessment such as Well’s with d-dimer estimation and imaging); and from AC about treatment. The prize this week goes to Dr Joshi for a well presented talk with excellent handout and quoted sources.

The discussion paper raised the importance of precision in diagnosis and communication. Investigations leading to a low probability of DVT are not the same as excluding DVT, even if the treatment decision is to not anticoagulate.

Next week’s theme is disorders which may present as ‘anxiety’:
Phaeochromocytoma (VJ)
Thyrotoxicosis
SVT (AC)
Hypoxia (CC)
Prescription Drugs (MJM)
Substance misuse (GAJ)
(we are not doing PTE since we have so recently done VTE)
wo minutes only, keep it concise and precise; quote your sources.

The paper for discussion on 22nd is Does This Patient With Headache Have a Migraine or Need Neuroimaging? Michael E. Detsky et al JAMA. 2006;296:1274-1283. Get it via the elibrary.

Interesting topics:
Retroperitoneal Fibrosis
The case for chocolate

MJM

Wardround 8ix6

This week’s discussions were disrupted by the ID team. No coincidence, I think, that the rheumatology discussion was subverted to ID. All part of the greater conspiracy? Next they will be claiming that rheumatoid arthritis is an infection.

Perhaps those who did not have opportunity to present will post some brief comments? Dr Joshi’s exposition on the safe use of sulfasalazine was well designed and practical, especially his final paragraph about responding to problems.

We will have to discuss the homeless man on another occasion.

For next week I have chosen neutral ground, neither primarily ID nor Rheumatology: Venous thromboembolism…assignments as below, though you may swap uif you see fit. If your name does not appear you can still do two minutes on an aspect of VTE.

Epidemiology (CC)
Investigation (VJ)
Treatment (AC)
Prognosis

Remember, only two minutes...keep it concise yet precise...quote your sources.

The paper for discussion is from the parliamentary ombudsman and relates to case 200501128
Read and think….have something to say.

Interesting topics this week
Thrombocythaemia
HOCM

MJM

Wardround 1ix6

The week's two minute talks were themed about antiviral treatment. Would each of you click the comment section and put in one sentence from your reading of the subject?

Next week we will hear about the safer use of DMARDs. The BSR last week published its guidelines for these drugs. You can get the local guidelines from my secretary. I had hoped to give a link to the BSR guideline but it has been taken off the website. I'll put in a link if it comes back. So we will hear about:
Methotrexate (CC)
Sulfasalazine (VJ)
Leflunomide (DL)
Etanercept (BW)

Next week's reading will be The homeless man on morning rounds. Jerome Lowenstein. I will leave a copy on the ward.

Interesting topics:
Homocysteine
Biventricular pacing

MJM