Tuesday, 24 March 2015

Pregnant but you don't know it

Hi,

Had a patient present a few weeks ago who reported she had not had a period this month. On questioning she was adamant she couldn't be pregnant as hadn't had sex recently, but agreed to do a pregnancy test for me. Unsurprisingly this test was positive. This left her in a difficult situation - she wanted to complete her education and her religion advised her against abortion, but she really didn't want to complete the pregnancy. After talking through the options I gave her referral details for the midwives and the abortion clinic, so she could choose which option she wanted to refer herself to after discussing with her family.

Today she came back, even more upset. She had decided that she didn't want to continue with the pregnancy and had attended the abortion clinic. As part of their work up they performed an ultrasound scan which revealed a 7 month old foetus (thank god for the scan!!)! This effectively took the choice as to what to do with the pregnancy away from the girl as this is far too old to consider abortion. We talked for a long time, and it turned out that she hadn't actually had periods for all this time, and had had unprotected sexual intercourse while on holiday in Europe at about the correct time. Eventually she came to terms with the situation.


3 main points from this:

1) This apparent virgin pregnancy was sadly not what it seemed

2) Some poor European man has a child he will never know about

3) Always examine the abdomen! If I had examined her I would have felt the baby!


As the streets might have said "You're pregnant but my gosh you don't know it" - and evidently neither did I! [Apologies for linking to terrible piece of music]

Thursday, 19 March 2015

Heart block and the breakdown of marriage

Hi,

Another little hiatus to blogging as I was on holiday! Coming back, I want to share an explanation of the different types of heart block using the breakdown of a marriage as a metaphor. I heard this explanation recently and want to share it with you mainly because I found it funny! 

Science stuff - heart block is a problem with the electrical conduction of the heart, which delays (or blocks) the normal signals progression through the heart muscle. Depending on the degree of this blockage you get different appearances on ECG, which are 'graded' into different types of heart block. Simplistically, the greater the level of heart block the more dangerous it is. Heart block is measured by the relation between the 'P' wave of the ECG and the 'QRS' complex of the ECG - see image below

P wave comes before QRS complex as shown here

The metaphor is a marriage and the washing up leading to the breakdown of this marriage.

Normal heart:

A good marriage with a slightly lazy husband. In this he sadly needs to be reminded to do the washing up every day. The P wave shows the wife having to remind him to do the washing up, and the QRS is him doing the washing up. At the early states of marriage he is good and does it every time promptly when asked. See normal ECG below:

Nice short regular spaces between P and QRS. Not much nagging needed!

First degree heart block:

Now comes the start of the marital breakdown. First degree heart block has a regularly prolonged period of time between the P and QRS waves. Here the hubby is getting a bit more lazy - every time he is nagged to do the washing up he delays it before doing it, perhaps leaving it overnight until the morning before doing it. This is due to poor conductivity of the electrical impulse in the heart slowing things down.

Look at those big gaps between the P and QRS. Leaving it to soak all night is not a valid excuse!


Second degree heart block - Mobitz type I (also known as Wenckebach): 

As things start getting worse in the marriage the husband now sometimes misses doing the washing up all together! In this situation the ECG shows a prolongation of the interval between the P wave and QRS complex each beat until it gets so long there is no QRS complex following the P wave at all. After this missed beat, the interval becomes short again and the process repeats. This is the husband becoming lazier and lazier, leaving the washing up longer and longer until he just cannot be bothered to do it. This obviously leads to an argument and then he has to buck up and he gets on with doing it properly again, but then becomes lazier and lazier until he misses another washing up. See ECG below

See the interval between P wave and QRS complex getting bigger until the whole QRS is missed, then repeating

Second degree heart block - Mobitz type II:

Here the husband just misses doing the washing up every so often because he is out of the house (with friends, with a mistress, we will never know). Here the interval between P wave and QRS complex is kept the same (perhaps due to guilt) but there is a regularly absent QRS complex. ECG is below

Intermittently the P wave is not followed by a QRS wave as it should be

Third degree heart block (complete heart block):

Here there is no association between the P wave and QRS complex at all - P waves are happening and QRS complexes are happening but they are not linked. The wife has become fed up with the husband and has left him - they are both doing their own washing up independent of one another in different houses.

Here you can see regular QRS but no relation to the P wave - some P waves fall before, after, or on other parts of the ECG.


That's the stages of heart block explained as though through marital breakdown. I thought it was quite funny and helpful to help remembering which is which. I hope you find them helpful too!

Friday, 20 February 2015

Definitely not pregnant

Hi,

Had a flummoxed patient come in to see me today after she had been started on the progesterone only contraceptive pill (or mini-pill) three months ago. She had been asked to come back in to assess how she had been coming along with this medication and to prescribe her more. After talking about how things were going with the pill, I offered to prescribe her a years worth, so she didn't keep to have coming back

"Oh, don't worry about that doctor, I've got plenty"

Confused, I asked what she meant, as her three month period was almost up

"Oh, I have lots left thanks. They gave me all of the stock the pharmacy had - they even had to get me to come back later as there wasn't enough to give me. I have a whole bag of packets left"

I was confused as to what had happened, but on further probing it turned out that there had been confusion and the script which had been issued by us for 84 pills (3 lots of 28 = about 3 months) had been cashed in by the pharmacist for 84 packets.

~6.5 years worth of contraception.

Tuesday, 17 February 2015

Mammaries

Hi,

Awkward consultation today where a middle aged women wanted to have a breast reduction. This is something difficult to negotiate at the best of times, as it is all about finding where that line between health benefits and cosmetic lies, but it was made so much more difficult by the fact that when she wasn't referring to her breasts as 'the twins' she was referring to her 'mammoth mammaries'. Her pointed enunciation of the letter 'm' throughout  these words, and the serious note she was clearly trying to portray by using this clearly medical phrase made it difficult to complete the consultation with a straight face.

In the end we decided that it would be quicker and easier if her boyfriend paid for the surgery

Saturday, 14 February 2015

The Great Cholesterol Con?

Hi,

Had a recurrent difficult consultation over the last few weeks - a lady had had routine blood tests done as part of her NHS health check which had shown a raised cholesterol. It is generally accepted (and pretty widely known) that high cholesterol levels lead to an increased risk of diseases such as heart attacks. This is based on a wide body of evidence from multiple studies and meta-studies backed up by government organisations such as NICE and mostly by the most important source of all - Wikipedia.

This lady had read a book called "The Great Cholesterol Con" which suggests that cholesterol is not linked to heart disease at all, and there is nothing to gain from lowering it at all. For this purpose she had started a "sausage diet" where she ate 1-2 sausages every meal, breakfast, lunch and dinner, along with the rest of her food. Predictably her cholesterol was crazy high. I tried to talk her through the evidence behind the ideas of lowering cholesterol, but I hadn't read the book so couldn't do this very effectively. I asked her to come back the next week so I could have some time to do some research. She was a little bit annoyed about this - she felt as a doctor I should know all this already, but agreed to return.

I read up on the arguments in the cholesterol book, which are based around inconsistencies in the Framingham Heart Study which suggested that as your cholesterol dropped, your risk of heart disease rose. It seemed as though this book was very selective in the data which it displayed to portray its arguments (well summed up by this review of a similar book) and ignored huge swathes of evidence which did indeed suggest high cholesterol levels (rather than just all cholesterol) are bad for you. You obviously need some cholesterol (and some salt, sugar, etc) but having too much can be a problem.

I collected up all of my research and information and bought it back to the next consultation with this lady. She was having none of it, and told me I had been taking backhanders from the statin producing pharmaceutical companies to peddle their wares. I tried to explain that as the patents on drugs such as Simvastatin had expired there would be no specific drugs company to try and pay me off, but the more I tried to disagree with her the more angry I made her. 

This was a loosing battle - I guess all we can do is display the evidence to the best of our ability and let people make decisions for their own health based on that. It was just upsetting that this wasn't a concious decision to damage her own health (like someone who smokes 40 a day, knowing full well it is bad for them) but a misinformed decision to try and help her own health, possibly guided by someone more interested in book sales than helping people. That said, she is coming back next week for another round of discussion, so wish me luck!
 
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