Saturday, September 27, 2008

HO, MO and Specialist (2)

Case 1

During ward round. MO's talking to an elderly patient rather loudly.
MO: "Uncle, what medications are you taking?!"
Specialist: "Hey, is that the way you're supposed to talk to pt? Must ask politely la." Turned to patient, "Hello uncle, may I know what medications are you taking?"
Pt: "Huh?"
Specialist: "Sorry uncle, I was asking what medications are you taking?"
Pt: "Huh?"
Specialist: "(raised the tone) Uncle! I'm asking you what medications are you taking ok!"
Pt: "Oh oh..i'm taking atenolol and metformin."

Specialist turned to MO and HO, "See, some patients if you don't raise your voice ah, they won't answer you one."

MO and HO: "......"

Case 2

During departmental meeting. Big bosses were making jokes about pharmaceutical companies.
HOD: "You all heard about '3F'? Something the drug representatives like to provide to buy our hearts. One is food, one is flattering, the last one I can't remember. Hopefully not something obscene."
Everyone got the joke and laughed out.

HOD turned to a blur-looking HO, "You know what are we talking about ah? What is the 3rd F?"
HO: "(answering seriously) Ah..err..Is it flatulence?"

Everyone: "......"

Related post:
HO, MO and Specialist (1)

Wednesday, September 24, 2008

Interesting Case!

Early morning at 8am, a patient was pushed into red zone. A 60 year-old man, no known comorbids, has history of fever and vomiting for 1 day, then noted became unconscious this morning. GCS upon arrival was only 3/15. Very limited history available. Family members claimed he has no history of recent travelling/ river swimming/ jungle trekking.

Clinically, his BP was lowish, having high grade temp, normal SPO2, ABG acidotic. Pupils, cardiovascular, respiratory, abdominal examination are unremarkable. Noted he has got generalized purpuric rashes, slight jaundice and no urine output. Capillary blood sugar "low".

So the clinical picture seems to be severe sepsis with multi-organ failure. But what is the cause of sepsis? And the hypoglycemia seems unusual in a sepsis case. Then I was informed by the nurse, the sugar after Dextrose 50% 50cc bolus, only increased to 1.5mmol/L, still low.

Wait, oh I think I got the diagnosis!

Some key treatment was given. He was sent to ICU.
Later the medical MO and physician also agree with the diagnosis.

What could be the most likely diagnosis?=)
(Answer's in my comment. Think before you open it!)

Tuesday, September 23, 2008

"Ada-ada" Syndrome (2)

Ok now we've gone through the definition of it, maybe we can share some tips on diagnosing it. And bear in mind that this syndrome is most commonly seen on Saturday morning (coz can get a 2-day MC for good weekends off) and Sunday night (feeling lazy to go back to work after enjoyed weekends).

From what I observed, most common "excuses" are headache, abdominal pain with diarrhea, low back pain, URTI symptoms and some others.

The key point is, patients can fake the symptoms, but rarely the signs. (Of course, it's possible in "professional" malingering pt or in factitious disorder/Munchausen syndrome etc.)

For complaints of cough/fever/sorethroat, it's not difficult to differentiate the "self-made" cough from the chesty ones. And, look for temperature, chest signs, injected throat or enlarged cervical lymph nodes. If they are present, then "Ada-ada" syndrome is unlikely.

For AGE (acute gastroenteritis) symptoms, you should be able to spot whether the abdominal pain is really "colicky" in nature, if you have experienced before. Things hard to be faked including the hydrational status, the abdominal tenderness and also the hyperactive bowel sounds. Look at pt's facial expression when you examine abdomen. Pt with "Ada-ada" syndrome, will forget about their abdominal pain with little distraction like, talking to them while examining the abdomen.

Low back pain are way too common. Some "smart" ones will know how to fake the SLRT (straight leg raising test). But there's a way to counter it. If you see a patient is able to sit upright with both knees extended on bed, and without pain, you know the SLRT is definitely negative. It's just same as you've raised their legs to 90 degrees!
And remember to look for muscle spasm. Tenderness is easy to fake but muscle spasm is a real sign.

Hmm I hope the tips will be useful. But I think the most difficult one would be "headache", as this complaint is so subjective, with hardly any obvious signs. Anyone has any good idea?=)

Ohya one last important diagnostic sign. If you see a patient who told you he has got severe back pain/ abdominal cramp, after given MC, walked off happily like healthier than you, it's highly suggestive of "Ada-ada" syndrome too.

But that will be a bit too late la. =)

Monday, September 22, 2008

The "Ada-ada" Syndrome

Ya, another newly-defined syndrome. To diagnose this, you need to learn some key phrases:

"ada-ada" means "got got"
"Kadang-kala" means "sometimes"
"Sikit-sikit" means "a little bit".

A typical conversation will be like this:

Dr: "So you said you've been feeling giddy these 2 days..any headache?"
Pt: "Ada."

Dr: "Severe throbbing kinda pain?"
Pt: "Ada-ada."

Dr: "Ok..what about fever?"
Pt: "Ada-ada-ada."

Dr: "Feel like vomiting?"
Pt: "Kadang-kala ada."

Dr: "Hmm..blurring of vision?"
Pt: "Sikit-sikit ada."

Dr: "Woo..(don't tell me you also have) abnormal jerking movement?"
Pt: "Oh..kadang-kala ada sikit-sikit."

Dr: "Then this is something serious. You need to be admitted for investigation."
Pt: (frightened) Oh no need la. Actually my problems are just little bit and sometimes only. No medication also nevermind. Maybe I just need to rest.

Can you give me MC for 1 week ah?"

Ya, there you go. When the word "MC" comes out, you know you're seeing the "Ada-ada" syndrome, a.k.a "Give-me-MC" syndrome. Very commonly seen, not easy to diagnose and quite difficult to treat. Basically they'll say "yes" to all symptoms, but in the end MC is the only treatment that they want.

I'll share some tips on handling this "disease" in my next post. =)

Sunday, September 21, 2008

Are You Sure This is "Love"?

"KATE MOSS’s little girl loves the smell of petrol fumes, says mum — who’s been partial to a sniff herself over the years.

Kate said that when she fills up she has to leave the car door open so Lila Grace, five, can catch a whiff.

Kate has just released new fragrance Velvet Hour and said of her daughter’s habit: 'I’ve heard it is one of the most preferred scents in the world — maybe that’s something to study for my next fragrance.'

Perhaps trendy Diesel might be interested in marketing that one.
And Kate gushed: 'I really miss Lila when I’m away — though I try not to be away for more than two nights.'

'I love her more than anything in the whole wide world.' "

- News from The Sun

This is just too bizarre. Instead of discouraging this gas-sniffing act to turn into a dangerous habit, this modern mum actually encourage whom she "loves more than anything" to indulge it?

Two very contradictory things, I think I just don't get it.

Love, anyone?

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