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.

Sir James Black Obituary

This picture is of red blood cells leaking from a damaged blood vessel. It was one of the winning pictures from the Wellcome Trust Image Awards 2008.

Last week saw the passing of Sir James Black, a truly remarkable Scottish scientist whose discoveries saved the lives of millions of people. He won the Nobel Prize for Medicine in 1988 and was chancellor of the university of Dundee from 1992 until 2006.

Some of his key drug discoveries included beta blockers and cimetidine for peptic ulcers which were for many years the world's biggest selling drugs. He studied medicine, and graduated in 1946 after which he joined the physiology department at the university of St Andrews. He began at to pursue an academic medical career. Initial research focused on blood flow related to rates of intestinal absorption by specific cell receptors of various substances. By 1956 he had set the goal of developing cell receptor modulators for various disorders but it was in 1963 at the university of Glasgow that he discovered propanolol and the role of beta receptors in controlling heart rate. He described winning the Nobel Prize as "the most exciting week I ever had" and the same year founded the James Black Foundation, a non-profit group of scientists engaged in new drug research. A truly remarkable man.

Also I have to say that I'm loving the BBC's "Wonders of the Solar System", hosted by 'the rockstar physicist' Professor Brian Cox, at the moment!

Cold Turkey, Blue Nails and Minimum Pricing.

Quick post this week - 4th year just seems to get busier by the week! This week I was reading the student BMJ (March) in which there were several interesting articles. Minimum pricing of alcohol was discussed, this seems to be an ongoing debate and will almost certainly have an important bearing on the next general election. I am definitely of the opinion that in the next 5-10 years there will be a massive change to the way in which alcohol is sold and consumed in the UK. The figures in Tayside alone show the scale of the financial burden to the NHS and the days of heavy boozing may soon be a thing of the past (good job my student days are nearly over then!).

The front page article on this month's student BMJ was regarding stem cell research however I've talked enough about this in previous posts (see below). Also covered in this month's journal was an insight into some disciplines which I previously had not known were present in the hospital. They are the critical care outreach teams and the bereavement officer. The critical care team can be contacted if there is a situation on the ward where a patient's state is deteriorating, presumably contactable at night, therefore it should never be the responsibility of a single doctor to manage a patient's care, nor should the doctor feel alone in this situation.

A moment for teaching: Wilson's Disease. This is an autosomal recessive inherited disorder of copper metabolism. Patients with this condition have impaired copper excretion and metabolism. Clinical signs of the disease are: eye signs (Kayser-Fleisher rings, extra-pyramidal disorders of movement eg. dystonia, psychosis and cirrhosis of the liver. Rarely the nails may appear to be a blue colour due to the effect of the copper.

Finally, there is recently published evidence that most quitters infact stop smoking without the need for additional support. Apparently often these patients are left out of trials and studies, partly because the research is not sponsored by any of the drugs companies which manufacture aids to help patients stop smoking.