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Poll archive

Posted in doc2doc feedback at Wed, 26 Nov 2014 10:49:54


Posts: 618
Joined: 18 Mar 2014

I love the new poll feature, its a great way to see what everyone thinks on some of these issues. What do people think of creating a page with all the previous poll results on?


Posted in Neurology at Wed, 26 Nov 2014 20:09:15

Mukhtar Ali

Posts: 872
Joined: 14 Nov 2010

Is there any modifiable risk factor for dementia . Day by day patient of dementia gradually increases so we prevent or halt the process of development of dementia. Non modifiable risk factors such as age, sex ,genetic . pl discuss.

Should patients have the right to record consultations?

Posted in News & media at Sun, 23 Nov 2014 19:48:23


Posts: 10
Joined: 31 Mar 2014

Hello everyone 

I'm replacing Matthew Billingsley as moderator (I've introduced myself in the new members' bit of doc2doc). So, here's my first discussion thread...!

An observation in the BMJ focuses on a discussion thread on a consumer forum about a patient whose doctor would not allow her to record her consultation. http://www.bmj.com/content/348/bmj.g2078

Patients were supportive of the patient's point of view, saying it was a form of note taking and she did not need to ask her doctor's consent. Doctors were, unsurprisingly, more cautious, saying that it could lead to defensive medicine. 

What do you think? Is recording a consultation a right? Or does it harm the doctor-patient relationship?

What should a fourth year Medical student learn from a four week attachment to UK General Practice?

Posted in General clinical at Tue, 25 Nov 2014 15:23:24


Posts: 1
Joined: 25 Nov 2014
We have a fourth year Medical student attached to our Practice for four weeks. I hope she will learn someting obout General Practice, learn some medicine and hopefully enjoy her time at this busy General practice. What things do you thing are the most important thing to learn from a General Practice?

Identify the lesion on the nose

Posted in General clinical at Mon, 24 Nov 2014 16:06:09


Posts: 1
Joined: 24 Nov 2014
Identify the lesion on the nose ---

Winter`s Blues

Posted in General at Mon, 24 Nov 2014 11:49:23


Posts: 618
Joined: 18 Mar 2014

Winter is around the corner---------with possible winter blues for some people, a medical condition called Seasonal Affective Disorder (SAD) it is believed that affected people react adversely to the decreasing amount of sunlight.

Do you know anyone with this medical condition?

Here is a beautiful quote from Albert Canus, the noble laureate

‘’ in the depth of winter, I finally learned that within me there lay an invincible summer’’  

Thank you for input

Should drinking during pregnancy be criminalised?

Posted in Medical ethics at Mon, 24 Nov 2014 10:58:22

Andrew Morrice

Posts: 22
Joined: 29 Jan 2009

The Court of Appeal is currently hearing a case brought on behalf of a seven-year-old girl who is claiming for payments from the Criminal Injuries Compensation Authority for the severe damage inflicted on her by her pregnant mother's heavy drinking.

The mother's high level of alcohol consumption was equivalent to attempted manslaughter, lawyers are arguing. 

The test case raises questions about whether the mother’s drinking constitutes a criminal act and whether the child was legally an individual the time she suffered injury. And, according to the Guardian, around 80 other claims on behalf of children suffering from foetal alcohol spectrum disorder are awaiting the outcome.

According to lawyers for the local authority, under whose care the girl now is, the mother drank up to half a bottle of vodka and eight cans of strong lager a day while pregnant, despite attempts by social workers and health care professional to get her to stop. The girl now has developmental problems. 

The case raises all sorts of questions: is a foetus a legal entity? What powers should professionals have over pregnant women whose behaviour causes potential harm to their unborn children?


What's your diagnosis? A returning traveller with fever, facial swelling and skin lesions

Posted in General clinical at Fri, 28 Nov 2014 04:15:16


Posts: 4
Joined: 29 Oct 2014

The case below was printed in the BMJ a few years ago. What are the possible differential diagnoses? I'll publish the answer in a few days. 

A 58-year-old man presented to the emergency department with fevers and lethargy. He had recently been in Zambia for 15 days, where he had spent time in Lusaka and at a game reserve. Three days earlier, while still in Lusaka, he had noted painful swellings on his right leg and fever, and although a malaria test was negative the fevers continued, so he returned home to Germany early.

At presentation, he was drowsy and his speech was slurred, so the history was obtained from his sister. He had not taken antimalarials during his trip, but he had been vaccinated against tetanus, diphtheria, and rabies before travel.

On examination his temperature was 39.4°C, respiration 18 breaths/min, pulse 96 beats/min, and blood pressure 95/80 mm Hg. His Glasgow coma score was 12/15, and facial swelling was noted around his eyes and cheeks. Apart from moderate hepatosplenomegaly and a systolic mitral valve click owing to a St Jude prosthesis implanted five years earlier, his physical examination was normal. There was no focal neurological abnormality or evidence of meningism. A generalised macular exanthema was noted on his trunk, along with two indurated skin lesions about 6 cm in diameter on his right leg (see below).

Blood tests showed haemoglobin 126 g/L (normal range 140-180), leucocytes 5.6×109 cells/L (4-11; lymphocytes 0.02 (0.25-0.4.), neutrophils 0.84 (0.50-0.75)), platelets 40×109 cells/L (150-400), C reactive protein 1807 μmol/L (8-31), creatine kinase 364 U/L (<171), total bilirubin 51.85 μmol/L (<17.0), aspartate aminotransferase 163 U/L (<35), alanine aminotransferase 205 U/L (<45), γ-glutamyltransferase 274 (<55) U/L, serum creatinine 477.36 μmol/L (<97). Serum electrolytes were within the normal range. Urine dipstick was positive for protein, erythrocytes, and leucocytes as well as some hyaline casts. Blood films were negative for malaria but showed unusual extracellular structures.

Should the performance data of individual doctors be published?

Posted in News & media at Tue, 25 Nov 2014 15:15:19


Posts: 4
Joined: 16 Aug 2014

From today the NHS website  has started to publish the performance data of individual surgeons in 11 specialties. Two more specialties - neurosurgery and urogynaecology - will come online soon.

The data has been provided by surgeons' own specialty associations and patients can search for individual surgeons by name. I've had a cursory glance at the data and, as a patient, I would find it incredibly difficult to understand and work out whether the surgeon booked to do my operation had a higher risk or not. 

Critics of the plan have pointed out that the data does not show whether the procedures performed by individual surgeons are high-risk or not. 

John MacFie, president of the Federation of Surgical Specialty Associations, said the data published was crude and misleading.

"In reality ver few deaths can be attributed to surgical error alone and this data only attracts attentio away from institutional failings," he said. He told Radio 4's Today programme that there was anecdotal evidence that publishing this data has encouraged risk-averse behaviour among surgeons. 

But Bruce Keogh, himself a heart surgeon and medical director of the NHS, told the programme that publication of the data means that surgeons and patients now share the risk of the operation.

He said: "That really focuses the mind about the appropriateness of surgery for that particular individual and well functioning surgery groups will share between them that risk and ensure that the most appropriate surgeon does the operation." 


Do you have to like your patients?

Posted in General clinical at Fri, 28 Nov 2014 08:53:18


Posts: 476
Joined: 23 Aug 2013

To have a good doctor-patient relationship do you have to like your patients? Do you ever give better/preferential treatment to patients you like better than others? Even if you do it unwittingly do some patients get more of your time and are you more willing to go that extra mile for patients whom you like better than others?

And do you ever suspect that your patients don't like you? Does it matter? 

I don't particularly like my GP but I think she's a good clinician so I'll carry on seeing her. But I don't think I would ever want her to give me bad news as her bedside manner is appalling.  

A tragic case, compounded by legal insensitivity.

Posted in News & media at Fri, 28 Nov 2014 12:31:35


Posts: 1710
Joined: 08 Oct 2010

You will have read of the poor mother of four children, three of whom had an incurable neurological condition, that would handicap their childhood and deny them adulthood.  She smothered them, while thier father and eldest daughter were away, and tried to kill herself.

I don't want to discuss the family and their tragic situation, but to ask if anyone else was as shocked as I was by part of  the prosecution counsel's case against her for manslaughter.     Ms Zoe Johnson QC argued that because she did not seek help for her depression,  she was culpable for the deaths of her children, even though the Crown Prosecution Service (who Ms Johnson represented) has previously accepted that she was mentally ill, and could not be charged with murder, but "only" manslaughter.

What breathtaking ignorance from an allegedly educated lawyer!    Surely the essence of depression is the loss of selfworth, the feeling that nothing can be done and that the sufferer isn't fit to live let alone be treated?   To say such a thing as a passing, unconsidered remark is at best insensitive, but to have that argument as part of the prosecution case is disturbing, as revealing ignorance in the UK's national legal system about the commonest mental illness of all .


Should 'bed-blockers' face legal action?

Posted in News & media at Tue, 25 Nov 2014 17:16:07


Posts: 83
Joined: 15 Jan 2010

There's an interesting story on the BBC today about a hospital in Bournemouth which is threatening to sue patients who refuse to leave hospital when they are fit to go.

About 70 patients are on wards in Bournemouth Hospital and are medically fit to leave, with around half that number having a home or care home to go to. The discharge manager at the hospital says families are giving spurious reasons as to why they won't take a family member and view NHS care as free board and lodging.

One family asked the hospital to keep hold of an elderly relative so they could have a two-week holiday in Turkey. 

Katie Whiteside, clinical manager for discharge services, told the BBC: '[Relatives] are deconrating the house or having a granny annexe built and they know that while the patients are here they are being fed, watered and looked after." 

The hospital is planning to give patients a week's notice to leave. 

I have some sympathy with the hospital which says that this is having a knock-on effect elsewhere in the hospital and the NHS is not a care home but what about the 35 patients who don't have a place to go to? 


Should patients address doctors by their first name?

Posted in General at Wed, 26 Nov 2014 11:35:02


Posts: 618
Joined: 18 Mar 2014

This week's poll idea stems from a thread discussing whether doctors should like their patients. Odysseus, who, despite his name, hails from Australia, wrote that many patients in Australia address their doctor by first name. "We are less impressed by societal stratification and titles," he says. 

There is quite a lot written about how doctors should address patients, including an interesting blog here. But if a patient asks you to call them by their first name should you return the courtesy? I call my dentist by his first name but I do see him fairly regularly - at least four times a year for my own and my children's check ups. He's a great dentist and I don't feel any loss of respect towards him - in fact, I feel we have a better relationship because he's so friendly and warm. 

I've never addressed a doctor by their first name but if I had a condition which required that I saw  a doctor regularly would I expect to address him/her by their first name? I'm not sure.

So what do doc2doc members think? 

What's your diagnosis? A teenager with a cough, fever and poor appetite

Posted in Respiratory medicine at Fri, 28 Nov 2014 16:16:12


Posts: 4
Joined: 29 Oct 2014

The article below appeared in the Endgames section of the BMJ a few years ago. I'll post the answer in a few days.

A 14 year old girl presented to her local hospital with a three week history of progressively worsening cough, fever, and poor appetite, which had not responded to a week of oral antibiotics.

On examination she had a temperature of 38°C, was pale, not clubbed, and her oxygen saturations were 95% in air. There was a dull note on percussion, with reduced air entry on auscultation in the right upper zone of the chest, and no added sounds. The rest of the systemic examination was normal.

At admission, blood tests showed haemoglobin 109 g/L (reference range 105-135), white blood cell count 12.7×106 cells/L (6.0-18), neutrophils 7.65×106 cells/L (2.0-6.0), C reactive protein 33 mg/L (0-5), erythrocyte sedimentation rate 116 mm in the first hour (10). Chest radiography and computed tomography were performed (see below). She was started on intravenous antibiotics and transferred to a tertiary centre for further management.

What abnormality do the figures show and what is the best way to manage it. 

A 30 years old man.....

Posted in General clinical at Fri, 28 Nov 2014 02:13:38


Posts: 663
Joined: 21 Feb 2012

A 30 years old man who has been treated for ulcerative colitis  presented with pallor; examination of a blood film showed reticulocytosis , fragmentations, and Heinz bodies :-


1/ What is the most likely diagnosis ?

2/ What is appropriate management ?



"Mental Health" and "Social stigma"

Posted in Public health at Fri, 28 Nov 2014 08:48:41


Posts: 476
Joined: 23 Aug 2013
Does Mental health still have a huge social stigma attached to it?

Is it difficult for a common man to accept Mental illness (especially in a close friend or relative) without undue affect on the social and personal relationships and networking?

Why don't we expect more from patients?

Posted in Respiratory medicine at Thu, 27 Nov 2014 21:07:15


Posts: 815
Joined: 13 Oct 2009

In this day and age the vast majority of people (excluding me) seem adept in handling all sorts of smart phones , iphones etc... as well as being computer literate. Yet we insist on insulting them whenever anything medical is being considered. The range of useful gadgetry that is available from those for measuring glucose and blood pressure to those for recording cardiac rhythm are simple to use and interpret - nothing in comparison to an iphone. Where relevant results can be sent through to the GP without need for an appointment. The own patient results can also be a better base for planning care. Yet as a profession we seem loathe to part with any of our mystique and pressures of work. Are we responsible for the dependency syndrome or is it something on which Joe Public insists?

Similarly we spend hours anguishing over how to present options to patients in advising over tests when the vast majority perhaps have a better understanding of what this information means to them - as opposed to studies on what happens on average to several thousand in some trial - and have access to the same studies anyway.

Of course there will always be those who can't participate in this but I strongly suspect that the main fault is that we try to protect our "status". But just think if we all had more time for those folk or discussions where gadgetry is no substitute.

I wonder what AnneG thinks as a non-medic.?


What's the most pointless piece of medical kit marketed to patients?

Posted in General clinical at Wed, 26 Nov 2014 21:21:12


Posts: 815
Joined: 13 Oct 2009

The BMJ has an interesting feature about wearable baby monitors - devices such as a sock that you can put onto your baby so that you can monitor his/her temperature, breathing, heartrate etc.

The chief executive of the company marketing the sock believes that one day every single baby will come home from the hospital with a wearable monitor. The devices will give parents "peace of mind and maybe even a full night's sleep" according to the blurb.

These devices will do the opposite - anxious first-time parents will work themselves up into a frenzy of anxiety as they constantly check monitors, wondering if their baby has died because the device shows no signs of life (when actually in their sleep-deprived state they have forgotten to charge the blooming thing). 

The whole wearable technology market seems to have gone crazy and this seems to characterise it. Have you seen other pieces of health kit that are similarly bonkers?


Why medicine is not like flying a plane

Posted in Medicolegal at Fri, 28 Nov 2014 11:19:14


Posts: 4444
Joined: 24 Feb 2009

I rather like Caroline Whymarks' blog (see http://www.hospitaldr.co.uk/blogs/caroline-whymark/medicine-is-not-like-flying-a-plane ).

The self explanatory title describes the topic.


Would you like to write for the BMJ?

Posted in General clinical at Thu, 27 Nov 2014 11:53:57


Posts: 618
Joined: 18 Mar 2014

The Endgames section of the BMJ - where I take many of the What's your diagnosis? articles from - is looking for authors to contribute case reports and picture quizzes for primary care doctors. 

The series was initially aimed at junior doctors but the editors would like to focus on topics included in the curriculum of the Membership of the Royal College of General Practitioners (MRCGP) exam. The new GP-focused articles will maintain a similar structure to the current Endgames reports while reflecting primary care practice where doctors face more uncertainty regarding diagnosis and management, deal with multiple co-morbidities and  social and family problems, have limited access to tests and examinations.  

The new series of articles could include some of the following questions:

  • What do these clinical findings mean?
  • What is the differential diagnosis?
  • What is the potential diagnosis?
  • Is the patient's social/family history relevant?
  • What would you prioritise in this patient?
  • How would you manage this patient?
  • What advice would you give to this patient?
  • What other concerns do you have regarding this patient?

To view recently published Endgames articles click here and to view the submission and author guidelines go to this link and click on the Endgames section or email Amy Davis: adavis@bmj.com



Posted in General clinical at Tue, 25 Nov 2014 21:25:13


Posts: 11
Joined: 19 Jun 2014

Any opinions on this new medical website designed to help physicians easily convert ADHD medications for their patients. ( I was asked to consult on it.). www.adhdmedcalc.com



Vale Phil Hughes

Posted in News & media at Fri, 28 Nov 2014 09:53:29


Posts: 618
Joined: 18 Mar 2014

A great cricketer who perished from a vertebral artery dissection at the SCG.

The whole nation is in shock. We all mourn. 

Surgery to treat obesity - is this the end of days?

Posted in General clinical at Fri, 28 Nov 2014 14:02:44


Posts: 618
Joined: 18 Mar 2014

New guidelines from the National Institute for Health and Clinical Excellence (NICE) have recommended that obese patients (body mass index of 35 or over) recently diagnosed with type 2 diabetes should be rapidly assessed for weight loss surgery. 

Nice says that out of 4000 patients with type two diabetes who had surgery, two thirds were no longer on diabetes medication two years later. 

While I understand the value of bariatric surgery there seems to be an apocalyptic feel to this guidance - have we reached the end of civilisation as we know it when large swathes of the population are so fat surgery is the only answer? It seems like something from a science fiction novel! 



Stigma of mental illness

Posted in Psychiatry at Fri, 28 Nov 2014 08:44:04


Posts: 476
Joined: 23 Aug 2013

A recently published article examined the patient's perspective of the stigma of mental illness, with respect to their age, duration of illness, education and nature of illness. One cannot but wonder about the possible causes of stigma, whether it is the behavioural problems that defy social norms at times, or the attribution to demonic possession and sinful life, or the attirbution to unconscious libidinal urges, or constructs like schizophrenogenic mother, high expressed emotions or segregation of mental asylums from general hospitals akin to what happened for certain dermatologic disorders eg the valley of lepers.

I wonder which factors do you find contributing most to stigma of mental illness. I hope to learn from you r insights and persepctives on this issue.

Is Big Pharma not so evil after all?

Posted in News & media at Fri, 28 Nov 2014 10:36:19


Posts: 618
Joined: 18 Mar 2014

An opinion piece in The Times rushes to the defence of Big Pharma - it's written to celebrate the promising results of GSK's Ebola vaccine. 

The article is behind a paywall so here are a few snippets:

"Big Pharma can't win. Develop a drug and it is accused of making us sick so that it can profit from our misery.... It is a different story when, as with HIV drugs, the product turns out to be undeniably effective in which case Big Pharma is expected to distribute it free to everyone regardless of the billions it cost to develop. If companies cannot make a profit on the few drugs that turn out to work after exhaustive tests they will not raise the capital to develop any at all. 

"If Bob Geldof, Bono et al were forced to give away all their music and throw open the dorrs to their concerts fo free we wouldn;t have much of a music industry. The same is true with Big Pharma."

What do you think? Does the author have a point or is he being too simplistic?