Diagnosing Death, Thyroid Disease and Medical Eponyms

<---Sunrise, Mt Sinai, Egypt. June 2009

Diagnosing Death - from the BMJ Podcast (16/04/10)

Dealing with death is probably one of the hardest things to cope with as a junior doctor, particularly if you are being faced with it for the first time. Here are a few tips on how to manage the situation:

Verify the death - check patient identity, observe patient appearance and note absence of any respiratory movements (over a 5 minute period). Auscultate over the chest and listen for heart/breath sounds. If any activity at all, reassess for a further 5 minutes. Check corneal reflexes, pupil response (reflexes) - pupils will be dilated and non-responsive. Check motor response (apply supra-orbital pressure) Check for pulses - carotid (both sides), radial and femoral. Wash hands. Make an entry in the patient's notes - date and time of death, findings on examination.

Breaking Bad News - Step back, take a deep breath, don't rush into the situation, think about your management plan. Communicate with family members, next of kin, what has happened. Do this in a private, quiet place eg. relatives room (clean and representable). Don't keep people waiting, turn off phone, pager etc and ensure NO interruptions. Use lines eg. "I'm sorry to say we have some very bad news". Use terms dead / died, as opposed to 'passed away', 'deceased' etc. Avoid common euphemisms. Discuss practical issues eg what will be done with the body, how the body is laid out. Inform the GP of the death.

Consider need for a post-mortem / referral to the procurator fiscal eg cause of death is uncertain, suspicious, accidental, violent, due to surgery/anaesthesia. If there is any cause for concern / suspicion, do not complete the death certificate - instead, discuss with a senior colleage.

Complete a death certificate. Ask yourself, am I the best person to complete this certificate? Legally someone can only complete a death certificate if they have seen the patient in the past 14 days. You MUST see the body after death. Once it is completed, it should be taken to the registrar of births and deaths (usually by the patient's next of kin). If there is any doubt, discuss with senior colleagues before proceeding.

Some OnExamination question corrections:
Differential Diagnosis - Thyroid Disease:
deQuervain's Thyroiditis - most frequently seen in young females. Often follows a flu-like illness. The patient commonly reports pain and a tender thyroid gland. It is usually a self-limiting illness.
Follicular Carcinoma - spreads haematogenously to the lungs. Treatment is with a total thyroidectomy. It presents with a firm neck nodule.
Anaplastic Carcinoma - rapid onset growth of a hard, woody thyroid lump which eventually progresses to acute dyspnoea. Abysmal prognosis.
Hashimotos's Disease - the commonest cause of primary hypothyroidism. Usually presents with signs of myxoedema. On examination there is a diffusely enlared non-tender thyroid gland.
Multinodular Goitre - may be asymptomatic or may present with pressure symptoms eg. dysphagia, dyspnoea or hoarseness. Particularly endemic in areas with iodine deficiency.

Medical Eponyms:
Rovsing's Sign - RIF pain exacerbated by pressing in the left iliac fossa (bowel is pushed onto the inflamed appendix) - classic in appendicitis.
Courvoisier's Sign - Law that states that in the presence of painless obstructive jaundice if there is a palpable bladder then the cause is unlikely to be gallstones.
Grey-Turner's Sign - Bruising of the flanks seen in retro-peritoneal haemorrhage.

Tumour Markers:
Carcinoembryonic antigen (CEA) is a commonly used tumour marker in colon cancer.
alpha FP and bHCG are markers raised in testicular cancer.

Engagement!

No post this week, Amy and I have just got engaged! Absolutely thrilled, so great to share it with both our families up in Dundee and with friends. Thanks to everyone for today!

Education Articles from the Student BMJ April 2010

Vitamin D deficiency

Causes Rickets in children and osteomalacia in adults. More than 50% of adults in the UK reportedly have a deficiency in vitamin D and the highest rates in the UK are in Scotland. Vitamin D is sourced from sunlight and from 1,25 dihydroxyvitamin D3 (calcitriol). Vitamin D status is best determined by assay of serum 25-hydroxyvitamin D (25-OHD). Vitamin D deficiency is associated with increased mortality and increased risk of common conditions such as cancer, cardiovascular disease and type 2 diabetes. Anyone who lives in a northern latitude country has an increased risk of vitamin D deficiency. At these latitudes, pigmented skin is also a risk factor.

Children: may present with bony deformity (Rickets), bowing of the legs (genu varum), irritability and reluctancy to weight bear. Height is more affected than weight. Management is with oral calciferol or colecalciferol to relplenish vitamin D stores.

Adults: present with proximal muscle weakness, bony pain, muscular aches, muscle weakness. Dif dx - fibromyalgia. Hypocalcaemia and hypophosphataemia may be present. Treat with calciferol.


Minor Eye Trauma

This was really a revision article in the student BMJ this week regarding the most common eye injuries which a junior doctor should have an idea about how to manage. Must rule out a head injury and must assess vision in both eyes and document this (legal requirement).

Corneal Abrasion - symptoms of intense pain, a watering eye and foreign body sensation with a clear history of a scratch / trauma eg 'A twig hit my eye'. To look for corneal abrasions, stain the cornea with flourescein dye. Treat with oral analgesics and topical antibiotics (sparingly because they delay wound healing).

Corneal, conjunctival and sub-tarsal foreign bodies
Feeling of 'something in my eye', symptoms of watering, red eye, pain, photophobia and FB sensation. Normally vision is unaffected. Metallic FBs leave behind a 'rust ring'. Examination should include eversion of the eyelids. Irrigate the eye using saline. Removing a FB usually requires a slit lamp and should be left to an opthalmologist.

Traumatic Subconjunctival Haemorrhage
Bleeding from the conjunctiva or episcleral blood vessels into the subconjunctival space. The eye is usually asymptomatic. If no co-existing injury the patient can be reassured. The blood usually disappears in 1 - 2 weeks.

Blunt-Eyeball trauma
eg. from squash balls. Can cause hyphaemas, retinal, choroidal tears, bony fractures. If vision is impaired - see an opthalmologist immediately. A fracture implies a severe injury.

Blow-Out Fracture of the Orbital Floor
Often occurs when a large object hits the face, commonly during sport or an assault. Patient may complain of diplopia, epistaxis, cheek numbness and a desire to blow the nose (which should be avoided). Assess ABC, rule out a head/neck injury and control any epistaxis.

Breast Cancer Screening Debate

Breast cancer screening debate

Is screening for breast cancer as effective as was previously thought in identifying disease? A study released this week put to bed some rumours that more people are treated un-necessarily than are helped by screening, showing that for every 2 people correctly identified and treated for breast cancer, one is treated un-necessarily.

Breast Cancer Screening

On the other side of the debate, this article from Denmark, reported in the NHS news says that the benefits are not as great as were previously thought.

Breast Screening Benefits Not Obvious

Then on the other hand there's the fact that at present, breast screening and mammograph is a very uncomfortable process, I was able to feel first hand how much pressure is necessary for a good image by putting my fist in a mammography screener and I remember being surprised as to how hard it presses down.

Perhaps the answer is more self-screening at home, I wonder how many people actually do this, it would be interesting to see what the uptake is like in Tayside (I predict quite low). Should breast examination be more routinely carried out as a physical examination in women age 50 - 70? Again I don't think most women of this age on a medical ward in Ninewells have this examination.