Should cardiology stop at the diaphragm?
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Should cardiology stop at the diaphragm?
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I saw a man in heart failure clinic last week who I was convinced had acromegaly - his hands really did look like spades and when he showed me a photo taken when he was 60 (he is now 71) I guessed it
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Forums » Open clinical » Cardiology » Should cardiology stop at the diaphragm?
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Should cardiology stop at the diaphragm?
posted at 9/2/2012 6:39 AM GMT
on bmj.com
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Posts: 446
First: 17/6/2011 Last: 15/5/2012 |
I saw a man in heart failure clinic last week who I was convinced had acromegaly - his hands really did look like spades and when he showed me a photo taken when he was 60 (he is now 71) I guessed it was from his 30's or 40's. I did an igf-1 as a screening test which came back high but not diagnostic. My endocrinology colleague tells me at the very least I should also have asked for a growth hormone level (I didn't). I have referred him on as clearly I'm not going to 'get ' the niceties of an acromegaly diagnosis. Should we all stick only to our areas of expertise or are we justified in screeing for diagnoses the present to us by chance? |
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Re: Should cardiology stop at the diaphragm?
posted at 9/2/2012 9:13 AM GMT
on bmj.com
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Posts: 2072
First: 10/3/2009 Last: 16/5/2012 |
I find most cardiologists monodimensional. They are fixated by their own brilliance. Who else but a cardiologist would have the expletive to talk about "non-cardiac chest pain" having done a cardiac catheter ($$$) and failed to elicit costosternal tenderness (for a few cents). Few ever palpate the chest in cases of chest pain but I may be wrong. Some are excellent and kind. They are my brothers. Imagine a thoracic physician talking about non-pulmonary dyspnoea or non-pulmonary chest pain??? I saw a man once who had been sent by a cardiologist for a respiratory assessment. As he walked in the door his appearance said "acromegaly". I diagnosed this and the sleep apnoea which accompanied it. In Australia all subspecialists are trained initially in internal medicine then subspecialise after their FRACP examinations which are very rigorous. If one wants to pretend one knows nothing but the details of their specialty I send them my condolences. I treat patients all day with a wide range of disorders. Sleep medicine is all encompassing, thoracic is a broad brush including occupational and medicolegal, overlapping with the rest of the body including the heart, kidneys, joints, skin, gut, gynae, CNS etc etc bla bla bla. You do a CT chest and abdomen for a chest and liver condition and find an adnexal mass.....non-cardiac...just forget it. I treat globally. Don't think you are above treating people as people and not just as hearts. I don't treat lungs. |
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Re: Should cardiology stop at the diaphragm?
posted at 10/2/2012 5:27 PM GMT
on bmj.com
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Posts: 446
First: 17/6/2011 Last: 15/5/2012 |
Thanks Odysseus, I appreciate that cardiologists get a bad rap and some of it is of our own making. I hope that we would all remember that we treat patients first and everything else second. My concern however is for things I don't often diagnose (and acromegaly is one of them) is my patient best served by seeing someone who sees the condition regularly and is uptodate with all the current treatments for all aspects including the diagnosis? |
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Re: Should cardiology stop at the diaphragm?
posted at 10/2/2012 6:06 PM GMT
on bmj.com
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Posts: 70
First: 15/8/2009 Last: 10/4/2012 |
In Response to Should cardiology stop at the diaphragm?: [It is only in recent decades that the idea of cardiology as being limited in this way came into being. Diagnostics for centuries included things like clubbing of fingers, color of the patient, and other physical signs. As we're learning, at the level of enzyme production so many systems are interrelated. To see cardiology as wholly other, apart from the patient realities and the physical realities of the patient in toto is probably...uh...limiting. |
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Re: Should cardiology stop at the diaphragm?
posted at 10/2/2012 6:37 PM GMT
on bmj.com
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Posts: 838
First: 12/3/2010 Last: 15/5/2012 |
This is the Joy of Anaesthesia! Our remit goes anywhere, and we see patients with everything. Just for instance, yesterday I had one with Alport syndrome and another with cirrhotic liver failure, and I'm currently reading up on Rosai-Dorfman syndrome, because I shall see a patient with it next week. OK, I don't have to concern my sleepy little head with long term outcomes and treatment alternatives, just the implications for aneasthesia and surgery, but those extend throughout the systems of the body. On some comments above, I have a very good relationship with 'my' cardiologist, who has a very sensible view about risk and treatment (IMHO). Others, interventionists who treat patients waiting for urgent surgery with drug-eluting stents, so that they must remain anticoagulated for a year, really must have their heads permanently between the horns of the C-arm. John |
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Re: Should cardiology stop at the diaphragm?
posted at 10/2/2012 10:45 PM GMT
on bmj.com
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Posts: 2072
First: 10/3/2009 Last: 16/5/2012 |
In Response to Re: Should cardiology stop at the diaphragm?: Thanks Odysseus, I appreciate that cardiologists get a bad rap and some of it is of our own making. I hope that we would all remember that we treat patients first and everything else second. My concern however is for things I don't often diagnose (and acromegaly is one of them) is my patient best served by seeing someone who sees the condition regularly and is uptodate with all the current treatments for all aspects including the diagnosis? Posted by sadian Sadian, the pre-subspecialty training for a thoracic physician, cardiologist and endocrinologist is the same. I don't accept that someone who has done several years in general medicine can't recognise a man with frontal bossing, large hands and a deep voice when we know that acromegaly has cardiac manifestations just as does haemochromatosis, and sarcoidosis. It doesn't wash for me. It is attitudinal. I am on the lookout for the enemy all the time and he does not have to be painted in wode with a big sign up saying "LUNG DISEASE" before I engage him. I think looking through a monocle and in the mirror too long may reduce one's visual field and produce a permanent scotoma aided and abetted by a certain self-satisfaction at the dizzy heights of attaining "cardiologist" after one's name. In my FRACP viva voce I had a long case of a well suntanned railway fettler, with bronze diabetes and cardiac involvement, from North Queensland and suffering paraplegia from a spinal abscess from melioidosis. Had I worn a monocle, I would have failed. |
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Re: Should cardiology stop at the diaphragm?
posted at 16/2/2012 5:38 PM GMT
on bmj.com
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Posts: 446
First: 17/6/2011 Last: 15/5/2012 |
Dear All - I'm glad to see that you all think that I should continue to examine things other than the heart. I think I was slightly deflated to realise that despite thinking of the diagnosis of acromegaly I hadn't asked for the appropriate tests! Anyhow I've dusted myself down and this week I can safely say that I've diagnosed urinary retention and an oesophageal perforation with mediastinitis. I still think however Odysseus that I would have failed your FRACRP - I got diabetes (standard type 2) with all the complications in mine. Sadian |
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Re: Should cardiology stop at the diaphragm?
posted at 16/2/2012 8:35 PM GMT
on bmj.com
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Posts: 2072
First: 10/3/2009 Last: 16/5/2012 |
I get bored with the thorax. There are so many adventures to be had south of the border. Cardiologists are mono-organed in outlook as I have said. I am blessed with double vision as there are two lungs. The heart is mere BlueTac holding them apart/ ?together. Indeed, the body is so complex, how could one not look beyond their favourite organ. The mind boggles. Yesterday a man came for a sleep review. He looked tired. He had been bitten by a tick and had just recovered from celullitis from it.... Another came and was exhausted and had been suffering arthralgias, malaise, headache and felt generally aweful. His CPAP was OK. How could I not want to sort this one out....Ross River Fever etc....he went away with some path slips after an examination..... The more you think generally, the better you are with your mono-organ. The lady yesterday with asthma?COPD, more breathless. Her flow volume loops were the same but she had become anaemic, her Hb lower because her eGFR had fallen and she was on calcium and vit D and her serum calcium a bit higher, bla,bla. Well, her asthma is just dandy. Conclusion as per monocle medicine: "Non-respiratory dyspnoea, pull lever and down to the cardiological crocodile pit which had devoured the the non-cardiac dyspnoea or do I try to change things???" Blinker vision and mono-organ narcissism lead to lousy specialty doctors who don't even know the eg cardiac complications of any other than ischaemic heart disease. How may cardiolgists do I see who have missed cardiac sarcoid. Even the all-wonderful CABG is really just palliative medicine, n'est-ce pas? Dust off Harrison, and dust off your brain. It might just get interesting.
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Forums » Open clinical » Cardiology » Should cardiology stop at the diaphragm?
