House Move and MRCP Part 2

It's all about the house move at the moment - here's a photo taken a couple of weeks ago inside the new house. Still quite a lot of work needing done but things are moving along well. Most of my time at the moment seems be spent either working, packing or studying. First set of CMT nights about to come up this week (starting tomorrow) followed by a week of annual leave!

MRCP Part 2 is about 6 weeks away now so time to do lots of practice questions. Here are some interesting topics which I've been revising over the past few days:

Spironolactone in heart failure - The RALES study showed that adding spironolactone to existing therapy in patients with severe clinical heart failure and an ejection fraction of <35 ace="" added="" already="" an="" and="" benefit.="" diuretics="" inhibitor="" loop="" shows="" span="" survival="" taking="">

Post-MI Mitral Regurgitation – A 56 year-old man becomes acutely unwell on the cardiology ward 4 days after an MI with evidence of acute LVF. Cause? Acute mitral regurgitation due to ruptured chordae tendonae. If blood pressure allows, these patients benefit from volume reduction using diuretics and initiation of an ACE inhibitor.

Cholesterol Emboli - The clinical syndrome associated with cholesterol emboli is: low C3 level, eosinophilia, raised ESR and urine proteinuria. Cholesterol emboli occurs in patients with existing arterial disease who undergo arterial manipulation – the patient develops a purpuric rash over the feet with impaired blood supply to the lower limbs.

 

Dermatitis Herpetiformis – This is an immune mediated blistering skin disease associated with gluten-sensitive enteropathy. Characteristically it causes a very itchy rash with blistering lesions over the extensor surfaces. First line treatment is with Dapsone. Dapsone is usually given initially because it allows for a faster recovery compared to a gluten-free diet alone.

Drug-Induced Hepatitis asoc with Anti-TB Therapy – Pyrazinamide should not be used in patients with known chronic liver disease. Rifampicin should be avoided where there is decompensated liver disease. Ethambutol can accumulate in patients with chronic renal failure leading to optic neuropathy and therefore should be given at a lower dose.

Progressive Supranuclear Palsy – This is a rare, progressive disorder that causes adult-onset Parkinsonism with postural instability and multiple falls. Impaired DOWN-gaze is always pathological (impaired upgaze can be seen in normal elderly patients).

Coeliac Disease – This is a common condition, with a prevalence of approximately 1 in 100 people (up to 1 in 30 in parts of Ireland). Severe malabsorption can lead to Vitamin D deficiency with secondary hyperparathyroidism, low albumin, impaired clotting, iron deficiency anaemia and weight loss. Iron deficiency anaemia is the most common presentation of coeliac disease and stool is FOB positive in approximately 50% of cases. The presence of other autoimmune conditions makes the diagnosis much more likely.

Invasive aspergillosis - This condition usually manifests with fever, cough, dyspnoea and pleuritic chest pain in patients with prolonged neutropenia or immunosuppression.

Safer Ward Rounds

HIS (Healthcare Improvement Scotland) was formed in 2011 - the same year I graduated from medical school, to support healthcare providers in Scotland to deliver high quality, patient centered, evidence based, safe and effective healthcare in our hospitals. The organisation links in to the pre-existing work which has been carried out in Scotland in this area, such as NHS Quality Improvement Scotland and the Scottish Patient Safety Programme, both of which I have talked about on this blog before. 

So why am I talking about HIS this week? Recently on the news it was reported that the hospital standardised mortality ratios in three Scottish hospitals were above the national average and as a result an inspection was launched by HIS to try and help find out why that may be the case and to offer assistance with improving the hospitals in question. Seeing as I currently work in one of the hospitals mentioned in the report, I have been aware of this visit for the past month or so and I think it is a definitely a welcome exercise. Hospital standardised mortality ratios are probably not a particularly reliable measure on their own to look at how well a hospital is performing as there are a huge number of factors which could lead to a higher mortality ratio in one hospital compared to another. It could reflect, for example, a more elderly or unwell population which are being treated, as opposed to being solely down to the quality of delivery of care in the hospital of note. I do however agree that these measures can be useful to 'flag' areas of potential concern. HIS is potentially an extremely powerful tool to improve healthcare and I think that helping hospitals which are needing extra support is an extremely worthwhile exercise. The team who visited my hospital this week comprised of almost 30 staff (a mixture of medical and non-medical background) and carried out various exercises such as walkarounds and discussion groups. It was great to see people talking about the processes in the hospital which could be improved. I was chatting to the nurses about things we thought were done well and things which could be improved in the ward we're working in, whereas we may not have been having these conversations had the visit not taken place. I look forward to hearing the outcome of the report although I have to say that since I started work in this particular hospital I've been impressed by the focus on improvement which I've seen with a big emphasis on clinical governance - definitely more prominent than in some previous hospitals where I have worked.

I thought about the meeting I had attended, with several other 'trainees' and thought about the various themes which emerged as people were describing areas where they though improvements could be made. I've decided that I need to take on a new improvement project or audit myself this year but up until now I've been quite undecided about what to do. I think what I might do is have a look at the way we do ward rounds in the general wards in the hospital where I work. A lot of the improvement work focusing on patient safety which I have seen being done or been involved in in the past has related to the use of 'bundles' and 'checklists' and I want to see if I can somehow create a safety checklist or bundle to help facilitate safer ward rounds. Already checklists are being adopted for safety purposes in other areas of medicine eg. surgery and I've ordered a copy of Atul Gawande's new book 'The Checklist Manifesto' which looks at exactly this topic. Once I've had a read through the book and perhaps done an audit to see if there is a problem in the first place, I can see if there is scope to improve our system. In the medical HDU unit in our hospital there is already a 'daily ward round' proforma sheet which is completed and prompts important questions ie. is this patient appropriate for escalation to intensive care if required or can this patient be stepped down to ward level. I don't see why an adapted version of this couldn't be employed in the general wards (ie. would it be appropriate to escalate this patient to high dependency or are they an appropriate patient for boarding out to another ward if necessary). A ward round checklist might not be as useful for the consultants who are much more experienced with ward rounds, but would help the junior medical staff who may be less experienced and therefore more likely to potentially miss things. I think that anything that improves overall communication from ward rounds would be an improvement and hope I can try and come up with something helpful.

A Diagnosis Easily Missed?

I gave a presentation this week at the hospital medical teaching meeting which focused on a case presentation: a diagnosis easily missed. A women in her 40s presents with headache, palpitations, intermittent sweating and flushing (particularly at night time) for about a month. Past medical history was unremarkable except for hypertension, treated with an ACE Inhitor, beta blocker and calcium channel blocker. Fundoscopy reveals hypertensive retinopathy and blood pressure is markedly elevated on examination. Blood results show acute kidney injury, but the full blood count, liver function tests and inflammatory markers are normal. A fasting blood glucose is also normal. Renal US scan identifies a cystic mass in the adrenal gland. Urine catecholamines measured over 24 hours are markedly elevated, as are plasma metanephrines. 

The diagnosis is: phaemochromocytoma. this is a rare tumour arising from the chromaffin cells located in the adrenal medulla. It has a very low population prevalence and there is often a delay of on average three years between initial symptoms and diagnosis. Approximately 1/4 of phaeochromocytomas may be incidental findings when a scan is carried out for another reason and in these cases the patient may be completely asymptomatic. In cases where patients experience symptoms such as the ones described here, they are thought to be casued by the secretion of catecholamines (adrenaline, noradrenaline) from the tumour, often in a cyclical pattern. The management of phaeochromocytomas is alpha-receptor blockade to reduce the effects of vasoconstriction caused by excess catecholmamines. Beta blockers may make the condition worse (think of a phaeochromocytoma in the hypertensive patient who gets worse after a beta blocker has been given). The definitive management is laparoscopic adrenalectomy to remove the tumour and the prognosis following this is excellent. It is worth noting that approximately 10% of phaeochrmocytomas are malignant and patients should be investigated for malignancy. Phaeochromocytomas may also be familial and are seen in conditions such as Multiple Endocrine Neoplasia 2A/2B, and Von-Hippel Lindau syndrome. 

So hopefully not a diagnosis easily missed any more after reading this!