Student BMJ: How to Present Clincal Cases

Education

How to present clinical cases

Presenting a patient is an essential skill that is rarely taught

• By: Ademola Olaitan, Oluwakemi Okunade, Jonathan Corne
• Published: 13 April 2010
• DOI: 10.1136/sbmj.c1539

Clinical presenting is the language that doctors use to communicate with each other every day of their working lives. Effective communication between doctors is crucial, considering the collaborative nature of medicine. As a medical student and later as a doctor you will be expected to present cases to peers and senior colleagues. This may be in the setting of handovers, referring a patient to another specialty, or requesting an opinion on a patient.

A well delivered case presentation will facilitate patient care, act a stimulus for timely intervention, and help identify individual and group learning needs.[1] Case presentations are also used as a tool for assessing clinical competencies at undergraduate and postgraduate level.

Medical students are taught how to take histories, examine, and communicate effectively with patients. However, we are expected to learn how to present effectively by observation, trial, and error.

Principles of presentation

Remember that the purpose of the case presentation is to convey your diagnostic reasoning to the listener. By the end of your presentation the examiner should have a clear view of the patient’s condition. Your presentation should include all the facts required to formulate a management plan.

There are no hard and fast rules for a perfect presentation, rather the content of each presentation should be determined by the case, the context, and the audience. For example, presenting a newly admitted patient with complex social issues on a medical ward round will be very different from presenting a patient with a perforated duodenal ulcer who is in need of an emergency laparotomy.

Whether you’re presenting on a busy ward round or during an objective structured clinical examination (OSCE), it is important that you are concise yet get across all the important points. Start by introducing patients with identifiers such as age, sex, and occupation, and move on to the complaint that they presented with or the reason that they are in hospital. The presenting complaint is an important signpost and should always be clearly stated at the start of the presentation.

Presenting a history

After you’ve introduced the patient and stated the presenting complaint, you can proceed in a chronological approach—for example, “Mr X came in yesterday with worsening shortness of breath, which he first noticed four days ago.” Alternatively you can discuss each of the problems, starting with the most pertinent and then going through each symptom in turn. This method is especially useful in patients who have several important comorbidities.

The rest of the history can then be presented in the standard format of presenting complaint, history of presenting complaint, medical history, drug history, family history, and social history. Strictly speaking there is no right or wrong place to insert any piece of information. However, in some instances it may be more appropriate to present some information as part of the history of presenting complaints rather than sticking rigidly to the standard format. For example, in a patient who presents with haemoptysis, a mention of relevant risk factors such as smoking or contacts with tuberculosis guides the listener down a specific diagnostic pathway.

Apart from deciding at what point to present particular pieces of information, it is also important to know what is relevant and should be included, and what is not. Although there is some variation in what your seniors might view as important features of the history, there are some aspects which are universally agreed to be essential. These include identifying the chief complaint, accurately describing the patient’s symptoms, a logical sequence of events, and an assessment of the most important problems. In addition, senior medical students will be expected to devise a management plan.[1]

The detail in the family and social history should be adapted to the situation. So, having 12 cats is irrelevant in a patient who presents with acute appendicitis but can be relevant in a patient who presents with an acute asthma attack. Discerning the irrelevant from the relevant is not always easy, but it comes with experience.[2] In the meantime, learning about the diseases and their associated features can help to guide you in the things you need to ask about in your history. Indeed, it is impossible to present a good clinical history if you haven’t taken a good history from the patient.

Presenting examination findings

When presenting examination findings remember that the aim is to paint a clear picture of the patient’s clinical status. Help the listener to decide firstly whether the patient is acutely unwell by describing basics such as whether the patient is comfortable at rest, respiratory rate, pulse, and blood pressure. Is the patient pyrexial? Is the patient in pain? Is the patient alert and orientated? These descriptions allow the listener to quickly form a mental picture of the patient’s clinical status. After giving an overall picture of the patient you can move on to present specific findings about the systems in question. It is important to include particular negative findings because they can influence the patient’s management. For example, in a patient with heart failure it is helpful to state whether the patient has a raised jugular venous pressure, or if someone has a large thyroid swelling it is useful to comment on whether the trachea is displaced. Initially, students may find it difficult to know which details are relevant to the case presentation; however, this skill becomes honed with increasing knowledge and clinical experience.

Presenting in an exam

Although the same principles as presenting in other situations also apply in an exam setting, the exam situation differs in the sense that its purpose is for you to show your clinical competence to the examiner.

It’s all about making a good impression. Walk into the room confidently and with a smile. After taking the history or examining the patient, turn to the examiner and look at him or her before starting to present your findings. Avoid looking back at the patient while presenting. A good way to avoid appearing fiddly is to hold your stethoscope behind your back. You can then wring to your heart’s content without the examiner sensing your imminent nervous breakdown.

Start with an opening statement as you would in any other situation, before moving on to the main body of the presentation. When presenting the main body of your history or examination make sure that you show the examiner how your findings are linked to each other and how they come together to support your conclusion.

Finally, a good summary is just as important as a good introduction. Always end your presentation with two or three sentences that summarise the patient’s main problem. It can go something like this: “In summary, this is Mrs X, a lifelong smoker with a strong family history of cardiovascular disease, who has intermittent episodes of chest pain suggestive of stable angina.”

Improving your skills

The RIME model (reporter, interpreter, manager, and educator) gives the natural progression of the clinical skills of a medical student.[3] Early on in clinical practice students are simply reporters of information. As the student progresses and is able to link together symptoms, signs, and investigation results to come up with a differential diagnosis, he or she becomes an interpreter of information. With further development of clinical skills and increasing knowledge students are actively able to suggest management plans. Finally, managers progress to become educators. The development from reporter to manager is reflected in the student’s case presentations.

The key to improving presentation skills is to practise, practise, and then practise some more. So seize every opportunity to present to your colleagues and seniors, and reflect on the feedback you receive.[4] Additionally, by observing colleagues and doctors you can see how to and how not to present.

Top tips

• Remember the purpose of the presentation
• Be flexible; the context should dictate the content of the presentation
• Always include a presenting complaint
• Present your findings in a way that shows understanding
• Have a system
• Use appropriate terminology

Additional tips for exams

• Start with a clear introductory statement and close with a brief summary
• After your summary suggest a working diagnosis and a management plan
• Practise, practise, practise, and get feedback
• Present with confidence, and don’t be put off by an examiner’s poker face
• Be honest; do not make up signs to fit in with your diagnosis

Ademola Olaitan, medical student¹, Oluwakemi Okunade, final year medical student¹, Jonathan Corne, consultant physician<sup>2

1</sup>University of Nottingham, ²Nottingham University Hospitals

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

See “Medical ward rounds” (Student BMJ 2009;17:98-9, http://archive.student.bmj.com/issues/09/03/life/98.php).

References

1. Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: Opinions of internal medicine clerkship directors. J Gen Intern Med 2009;24:370-3.
2. Lingard LA, Haber RJ. What do we mean by “relevance”? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format. Acad Med 1999;74:S124-7.
3. Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med 1999;74:1203-7.
4. Haber RJ, Lingard LA. Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications. J Gen Intern Med 2001;16:308-14.

Cite this as: Student BMJ 2010;18:c1539

Thanks Joe for sharing the article!

Free OSCE Revision Videos

Click here to access OSCE revision lectures. They are by delivered by the guy who wrote the Pastest OSCE book. Apparently, they are easygoing and good for quick revision if you have spare time.

Thank you Noura for sharing the link and good luck with your exam!

My Personal Tips for the Step 1 by CartoonDoc

This was posted by CartoonDoc (A Cartoon Guide to Becoming a Doctor: http://doccartoon.blogspot.com/) on studentdoctor.net's forum.

1. Your worst subject which will comprise 50% of the exam. The other 50% of the test will be on the female pelvis.

2. Most exam takers will bring ear plugs to protect themselves against noisy people in the room. It is also recommended to bring nose plugs to protect against smelly people in the room. You might also want to blindfold yourself to protect against ugly people in the room.

3. When in doubt, the answer is priapism (the painful prolonged male erection).

4. Regardless of chief complaint or symptoms, every African-American female on the exam has sarcoidosis or possibly lupus. Every Caucasian female has either pelvic inflammatory disease or thyroid dysfunction. The rest of the spectrum of disease is represented in men. Just like in real life.

5. If it's any comfort, nothing you're about to be tested on or have killed yourself learning for the past two years will be at all relevant to your future career. Do you feel better now?

6. The same #1 basic guideline applies as to every other exam you've ever taken: Never fall in love.

7. If you do badly the exam, you can always build a time machine, go back in time, and fix your score. If you do so, just make sure your mom doesn't fall in love with you because it'll, like, disrupt the space time continuum or something.

8. Due to increasing incidence of cheating, proctors have been instructed to perform randomized body cavity searches during the exam. So you may want to rethink some of your old hiding places from the MCATs.

9. Statistically it's been shown that students' scores on Step 1 are reflective of their performance over the past two years, so any studying you're about to do for the exam will statistically be a waste of time. But, you know, don't let that stop you.

10. If all else fails, there's always Plan B: Hide under a pile of coats and hope that everything turns out OK.

Hope that helps!!!

A Cartoon Guide to Becoming a Doctor: http://doccartoon.blogspot.com/

Drugs!

Drugs are a high yield topic in the USMLE Step 1 + 2. Some of their effects can be hard to remember if you're not a junkie. Do not despair, Sponge Bob is here to help (Nicked from His & Her Blog http://hishersq8.com/)

Case Study - Age No Barrier (from the Medical Protection Society, Case Reports)

Age no barrier

A seven-year old girl, MA, complained to her mother of stomach ache. She was usually very stoical, but was complaining and not wanting to play. Her mother, Mrs A, was concerned and rang the surgery to speak to her GP, Dr G.

Dr G told her to give her daughter some paracetamol, but did not document the conversation in her notes. The next day, MA was still suffering so Mrs A requested a home visit. The GP went to their home and quickly diagnosed a UTI without examining the girl and prescribed trimethoprim. Dr G made only very brief notes, just mentioning the abdominal pain and the antibiotics prescribed.

According to her mother, Dr G did not stay very long, did not examine her daughter and did not ask for a urine sample to test. Mrs A asked Dr G whether it could be appendicitis, as the pain was on the right side. Her friend’s daughter had recently had appendicitis, which had been right-sided. Dr G said that MA was “too young for that”.

The following day, MA had started to vomit and seemed in much more pain, despite having taken paracetamol. She was also warm to the touch so Mrs A rang the surgery again. A different GP, Dr P, informed her that “antibiotics take time to start working” and to allow another couple of days to see if she improved. Again, the GP made no record in her notes of their discussion on the phone.

Three days after the pain began, Mrs A took her daughter to the Emergency Department (ED). By this time she looked very unwell. She was pale and was lying very still. She was in a lot of abdominal pain if she tried to move. She was vomiting and could not keep any food or drink down. The surgeons diagnosed acute peritonitis and took her straight to theatre where they found a perforated appendix. MA had a miserable stay in hospital, needing intravenous antibiotics, but she did make a good recovery.

MA got married when she was 29 and decided to try for a family. After two years of trying, she still was not pregnant and so went to discuss this with her GP. She was referred for tests and found to have blocked fallopian tubes and pelvic adhesions.

The specialist thought this was likely to have been caused by the perforated appendix and resultant pelvic adhesions years before. MA was very upset and made a claim against Dr G and Dr P. The claim was settled for a moderate sum. Although Dr G had died by this time, so was no longer in membership, the fact that he was a member of MPS at the time of the incident meant that MPS was able to respond to the claim.

Learning points

• It is very important to examine a patient with abdominal pain. Doctors must adequately assess the patient’s condition, taking account of the history, the patient’s views and, where necessary, examining the patient.¹ Failure to examine the patient’s abdomen made the case indefensible.
• Always be prepared to reconsider a diagnosis made by another doctor.
• Some pathologies, such as appendicitis, are more common in certain age groups, but are still possible in others. Differential diagnosis needs to consider both the usual and the unusual.
• Simple tests like dip-sticks are there to be used and are helpful in evaluating the likelihood of a diagnosis of UTI. Diagnosing a UTI with no evidence may not be safe.
• Clear, comprehensive documentation is an invaluable way to ensure good communication with colleagues when patients are seen by different doctors.
• A good defence is almost impossible without good documentation. Doctors must keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment.²
• There may be long delays between the incident and a claim being made, which demonstrates the strength of occurrence-based indemnity. Claims can be brought years after a doctor has retired, or even died.

References

1. GMC Good Medical Practice 2006, good clinical care, paragraph 2a.
2. GMC Good Medical Practice 2006, good clinical care, paragraph 3f.

From: http://www.medicalprotection.org/ireland/casebook-january-2010/case-reports/age-no-barrier

Thanks to Marwan Al-Qenaie for sharing this case study!

Subscribe to KMS's Video Podcasts on iTunes!

We now have all KMS's videos available on iTunes to view/download for free. Just search for 'Kuwait Medical Society' on iTunes or visit http://kmsukir.blip.tv and click on the link below the video that say 'subscribe to iTunes'.

The videos are formatted so they can watched on your iPods/iPhones or offline. You can subscribe to the podcast to receive our latest offerings. We will use this service to provide more educational material so keep watching this space!

Video Coverage from the Careers Days

In addition to photos from the Careers Days (see previous post), we also have... wait for it... VIDEOS of all that took place on Careers Days! So for all KMS's friends in the UK/Ireland who couldn't be home for Christmas to attend, we are sorry you couldn't be there but at least now you can watch all the proceedings from the comfort of your sofa at home. We would be immensely grateful if after watching the videos you e-mail us at kmsukir@gmail.com to let us know what you liked/didn't like about the conference and if you have any suggestions (if you're interested in becoming an active KMS member, or to to learn about future events, let us know in the e-mail).

To watch Careers Day visit our page on blip.tv

http://kmsukir.blip.tv

You can also watch the videos embedded in this blog if you scroll down to previous posts

Coverage includes:

Day 1: Getting into a Speciality - 4 videos

Day 2: The Specialties Panels + Dean's Speech

(Specialties covered = Medicine, Pediatrics, Surgery and Other Specialties)

The careers event took place at Kuwait University on the 29th-30th December 2009. KMS would like to repeat its appreciation for all the help it received from KuMSA, Kuwait University, Dr. Altayyeb Yousef and his fellow speakers who deserve full credit for Day 1 and the panelist for taking part.

How can sugar pills cure diseases?

Ben Goldacre, doctor and author of 'Bad Science', explains what the placebo effect is and describes its role in medical research and in the pharmaceutical industry.

For more about this subject, you can buy the bestselling book, 'Bad Science' by Ben Goldacre, from Amazon

Sex and its Problems... A Crash Course!! Part 2

Psychosomatic Sex Cycle (adapted from Bancroft (2009))

So we've briefly touched on the components of the sexual response. Let's explore now the problems and their prevalence in males and females.

1/ DISORDERS OF SEXUAL DESIRE

Impairment of sexual desire can occur in both men and women; however lack of desire most commonly affects females with 60-70% prevalence rate.

Sexual desire correlates with the testosterone:oestrogen ratio in both genders so that a higher ratio is associated with increased sexual desire. Inhibition or lack of interest is broadly either psychogenic or organic in origin. Psychological factors include early parental problems, society or past experiences eg rape/incest. Organic causes include hyperprolactinaemia due to a pituitary adenoma (if impaired sexual response co-exists with symptoms of headache and impairment of peripheral vision- think pituitary adenoma!!). Diminished testosterone:oestrogen ratio may lead to lack of desire.

Management includes assessment for an underlying organic problem. Psychological problems are far more common, and a good history taker would be able to identify how patient attitudes of past and current relationships, any guilt or indication of early childhood problems contribute to the problem. Relationship therapy and taught focus exercises might be of benefit.

2/ DISORDERS OF SEXUAL AROUSAL

This is represented by erectile difficulties in men and by lack of lubrication and of general sexual responsiveness in women.

IN MEN

About 85% of cases with erectile dysfunction are organic in origin. Risk factors include obesity, lack of exercise smoking, high cholesterol, hypertension and diabetes.

- organic causes;

VASCULAR= atherosclerotic change in penile blood vessels (accounts for half of cases)

NEUROLOGICAL= can be either central (eg in Parkinson's, MS, spinal cord syndrome) or peripheral in origin (eg peripheral neuropathy like diabetic neuropathy or GBS, alchoholism, uraemia).

HORMONAL= Hypoganadism, Cushing's and thyroid diseases, hyperprolactinaemia

ANATOMICAL= Peyronie's disease

DRUGS = beta blockers, diuretics, Cu channel blockers, hormonal agents eg cyptotenone acetate,LH releasing analogues, H2 antagonists eg cimeetidine, ranitidine.

2/Psychogenic causes

- psychosexual factors (can be general due to a disorder of sexual intimacy and lack of arousability or situational due to partner or stress)

-Psychiatric illness ( Generalized anxiety disorder, depression, alcohol dependency)

Management - involves

- history taking ( ask about current/past sexual relationships, current emotional status, erectile symptoms eg onset and duration, arousal ejaculation and orgasmic difficulties). don't forget drug and social history. Latter is important to look for drinking problems, smoking, home situation, difficulties at work/marriage.

-Investigations - blood glucose, U&Es, urinarlysis, LFTs if indicated. If patient also has reduced sexual drive or abnormal sexual characterization, check testosterone levels, LH/FSH, prolactine (especially in young men).

Treatment - correct the underlying cause whether organic or psychological. First line symptomatic treatment is with phosphodiesterase inhibitors (sidenafil, tadafil, vardarefil) or vacuum devices eg external cylinder - one study reported that 23% asked for a prescription after a 2-week trial and 52% reported satisfaction (suitable for older patients).

IN WOMEN

Lack of arousal may be caused by inability to respond to sexual stimulation with dilatation of venous vaginal plexuses and lubrication to reach orgasm.

The causes are;

1/psychosexual;

- inhibitions from learned attitudes, past experiences or marriage difficulties.

- situational anxiety eg about a baby, in parental house

- inadequate stimulation from an inexperienced lover is often a cause of early difficulties

2/ organic

- Causes include drug side effects, neurological problems (MS), vascular disease (Diabetes), postmenopause (low oestrogen).

- Inadequate stimulation or lack of arousal may accompany dyspareunia, which is pain during a sexual intercourse. Fear of pain with intercourse causes anxiety with or without sexual reponse leading to vaginismus (contraction of pelvic muscles resulting in failure of penetrative sex) and more painful intercourse thus creating a vicious cycle.

For medical students reading this, dyspareunia is not an uncommon history station in your OSCE. You have to think of a differential. This depends on the site of the pain, which classifies dyspareunia into introital, midvaginal or deep.

Introital dyspareunia is caused by

-inadequate lubrication or vaginitis (eg due to STI)

-vaginismus

Midvaginal caused by

- urethritis, congenital vaginal abnormalities

Deep dyspareunia caused by

- endometriosis (ectopic bleeding uterine tissue outside uterus), adenomyosis (bleeding uterine tissue within uterine muscle layer), leiomyomata (benign uterine cancer), pelvic inflammatory disease, uterine retroversion or ovarian cyst.

Management

- Take a good history; if patient reports painful intercourse, ask about onset, duration and site of pain, and whether pain occurs with arousal or at penetration. Ask about associated symptoms eg rash, irritation, smell (local aetiology), vaginal discharge (STI), heavy periods and menstrual irregularities (endometriosis) and menopausal symptoms and any dragging sensation (prolapse).

- pelvic and speculum examination

-treatment; to correct the underlying cause. The cycle of fear must be broken in order to stop the pain if no evidence of organic aetiology and anxiety/vaginismus induced dyspareunia is suspected. A specialized Kegel exercise of the pelvic muscle is taught to the patient to learn how to relax pelvic muscles during an intercourse. Lubricants may be used in case of indequate lubrication.

3/ ORGASMIC DYSFUNCTION

5-10% of females report anorgasmia, which can either be primary (never been able to achieve orgasm under any circumstances) or secondary (diminished ability to active orgasm despite previous successful attempts). A study by Kinsey in 1953 found that 9% remain unable to experience orgasm throughout their lives.

Psychosexual factors include fear from momentary loss of control experienced during orgasm and unable to relax and let go. Vaginismus can cause orgasmic dysfunction as well as impaired arousal. Other physical factors include lack of normal bulbo-cavernous reflex which causes failure to reach orgasm.

I hope this brief post made a useful introduction into medical problems affecting sexuality, which is normally a big and complicated area. For further reading, please explore the references below.

Information was adapted from;

- www.patient.co.uk (highly recommended for non-medical readers)

- John Bancroft, human sexuality and its problems. 3rd edition. 2009

- David Goldberg, Linda Gask and Richard Morris. Psychiatry in medical practice. 3rd edition. 2008

Sex and its Problems... A Crash Course!!

Sexual problems are badly taught in medical school curricula despite their common prevalence, which represent the top of the ice-burg since many choose not to seek medical advice out of embarrassment or lack of awareness.

For example, one large US survey found that 43% of women and 31% of men between the ages of 18-59 complained of some form of sexual problems during the preceding 12 months. Whereas 2/3rds of men referrals were due to erectile dysfunction, women complained of loss of desire and impaired sexual interest, which commonly co-existed with relationship problems and other problems with arousal.

Hence the purpose of this brief report is to raise educational awareness of these problems and outline a general framework for a differential. First, we illustrate how 'sex' normally works in this post followed by an exploration of related problems in a second post later. So keep tuned!!!

The sexual response consists of 4 essential steps as shown in the diagram;

1/ DESIRE; it is the energy that allows an individual to initiate a response to sexual stimulation

2/ AROUSAL; this is the physical and emotional stimulation leading to breast and genital vasodilatation and clitorial enlargement.

3/ ORGASM; Physical and emotional stimulation maximized allowing the individual to relinquish their sense of control

4/ RESOLUTION; most of congestion and tension resolves within seconds. Complete resolution may take up to 60 minutes.

If you look at the diagram - The frontal cerebral cortex, the thinking part of your brain, feeds positive cognitive stimuli into the limbic system, the seat of your emotions!! ie this loop is where sexual DESIRE is coordinated and governed by individual's attitudes fears and experiences. Through spinal neuronal circuits, the limbic system exerts its stimulating/inhibiting influences on sexual AROUSAL represented by peripheral arousal (respiratory and cardiovascular effects) and genital responses. In order for the individual to know that arousal has taken place, a sensory feedback system sends information to the brain establishing that physical effects of arousal occurred. Tactile/sensory stimulation stimulates the limbic system through spinal centers, and that contributes to ORGASM. Therefore, functional availability of the limbic system and spinal centers are prerequisite for orgasm.

Now, it's easier to think of sexual disorders generally as problems of desire, arousal or orgasm. We'll explore this part next.

Reference

John Bancroft. Human sexuality and its problems. 3rd edition. 2009. Edinburgh

Queen's University Belfast Scrubs EM Conference BOOKING NOW

Dear Medical Student,

Just to let you all know that the medical and surgical society QUB Scrubs is now taking bookings for our Emergency Medicine Conference on Tuesday and Wednesday 9th & 10th March. The conference is going to be held at the Medical Biology Centre at Queen's University Belfast.

The conference is the highlight of our calendar- it's a national conference tailored specifically for undergraduates. It is a 2 day event, with delegates coming from all over the UK and the Republic of Ireland as well as from Queen's. It's not just for students in their clinical years either...it is a fantastic learning opportunity for students from all years, so why not come along to learn, to present your research and have some great craic with other medical students from all over the country?!

FULL DETAILS CAN BE FOUND ON OUR WEBSITE BUT HERE IS A BRIEF SUMMARY BELOW!

WHAT'S INCLUDED?
Day 1 of the conference focuses on expert seminars- a huge number of specialties are covered from paediatrics to trauma surgery, and from management of oesophageal varices to acute poisoning. Day 2 is much more hands on- it is the practical skills workshop, focusing on things like ABGs, immediate life support, suturing, radiology (perfect OSCE preparation).

* Food is provided on both days
* Delegates will receive conference bags with goodies from Scrubs, Wesleyan and MPS who will be attending
* Spot prizes throughout both days

WHAT ELSE?

* If you have done an intercalated degree/original research/audit/literature review and wish to come along to present you work you can do so- just submit an abstract to us via email by Tuesday 9th February. Points are awarded on the UKFPO application for presenting work at conferences so why miss out? We are planning to have our conference party on the first night this year, so that anybody travelling won't miss it if they have to dash off for flights after the second day. We are planning to have the meal/party in Victoria Square on the night of the 9th March- all delegates are invited as well as the speakers.

HOW TO BOOK
If you like the sound of that you can book online via our website; the 2010 Conference page at www.scrubs.society.qub.ac.uk has all the details and info on how to book. We have kept the prices the same as last year- £15 for members and £20 for non-members.
However, we now have double the number of members than we had last year, so with limited places it would be a good idea to book quickly. We know not everybody will want to present research or go to the dinner, so you can opt out of those. At the bottom of the 2010 Conference page on the website just follow the simple instructions.

* In the first box select whether you are a member or non-member, and you can add the evening meal ('dinner') for an additional £10, or add a research presentation ('RP') for an additional £5, or both. * Please fill in the second box (just stick in QUB). * Regardless of whether or not you are having the evening dinner put any special dietary requirements in, because we'll be providing lunch on both days.

Payment is via PayPal, which is totally secure. Information about where to stay can be found on the conference page of our website!

If you have any general queries, or any problems booking just send us an email and we'll get back to you as soon as possible.

We'd love to welcome you to Belfast in March!

Luke Boyle
President, QUB Scrubs

Thanks to Yaqoub Al Qattan for the information

Don't miss; Psych, Neuro and Ophthalmology this weekend in London

The Royal Society of Medicine in London is planning a medical student revision day on Sunday 14th Feb for the three tricky specialties...

Neurology Ophthalmology Psychiatry

If you feel you are not confident in these areas, then I promise that you won't regret spending the weekend in London! The clinical lectures are of high standard and handouts with power point slides are provided.

http://www.rsm.ac.uk/students/sta16.php

Edward Cullen's Disease

Since people have recently gone vampire mad, I thought I'd share some vampire medical trivia.

Some historians claim that the vampire/werewolf folklore emerged from the symptoms of a certain disease. Can anyone guess what condition is linked with tales about vampires?

What would you do for plantar fasciitis?

Plantar fasciitis is a very common complaint that affects 10% of the general population at least once in a lifetime. Here's a video from the Mayo Clinic about what to do about it:

Can You Workout the Diagnosis? Can't walk, Can't talk and failed to respond to antifungals!!!

PRESENTING COMPLAINT

67 year-old gentleman with PMH of T2 diabetes, HTN, OA, bilateral knee replacement (2009) is referred to neurology services for evaluation of difficulty walking and slow progress in mobility after his knee surgery.

HISTORY OF PRESENTING COMPLAINT

The patient had 2 falls in the past 2 months. Progress with physios is very slow. Referred to his GP because of slow movement and slurred speech and symptoms of urinary frequency. GP prescribed antifungal treatment (no idea why? apparently his GP doesn't know that neurology exists;)

A month later, the patient experienced rapid decline of his mobility needing a walking stick initially and using a wheelchair currently. In his letter to neurology, the GP describes that patient is feeling his foot is glued to the floor and has enormous difficulty lifting it off.

Patient has occasional choking on bread and weight loss of 1 Kg over 6 months. But no smell, visual or taste problems. No problems with chewing, sleep disturbance. Upon further questioning, the patient also denies experiencing postural dizziness and there is no sudden bouts of uncontrollable laughter or crying (what do neurologists call this symptom? -Hint: common in patients with stroke)

OTHER HISTORY

Drug History - aspirin, amlodipine, omerprazole, insulin homologue

Family History - irrelevant

Social History - ex-smoker, drinks no alcohol

ON EXAMINATION

The patient appeared relaxed and slightly underdressed. Despite a room full of neurologists, he was very unnerved, and was joking and laughing. Dealing with audience questions, he would answer the question and then say 'Next'!!

His speech is slurred and dysarthric, better described as strangulated speech with words produced from the back of the mouth. In addition, there is an element of staccato speech when asked to say 'British constitution' or 'West Register Street'.

Gait- magnetic with a degree of stamping and difficulty of initiation. Stride is really slow at start, but improved slightly with 3rd and 4th step with increasing speed. Postural instability with stooped posture. Normal base.

CRANIAL NERVES

Normal range of eye movements. No restriction of upward gaze. No diplopia, squint or ptosis. Saccadic eye movement is normal. facial and mastication muscles are not weak or wasted. Absent jaw jerk. No wasting, fasciculation or weakness of the tongue. Rest of exam is also normal.

UPPER AND LOWER LIMB NEURO EXAM

Wasting and fasciculation of right wrist extensors. Tone is increased in upper and lower limbs - it is velocity dependent with a spastic catch. There is mild cogwheel rigidity in upper limbs. Global hyperreflexia (more predominant on R>L upper limbs). Positive Hoffman's reflex. No clonus and upper plantars are equivocal.

Finger-thumb test showed time-dependent reduction of velocity and amplitude of movement with 'fatiguability'.

No dysmetria, intention or resting tremors, dysdiadokokinesia or nystagmus.

INVESTIGATIONS

A number of investigations were performed. Results of investigations are provided upon your request.

What is the diagnosis? and Why?

Hint: Start by naming pathways in the nervous system, the involvement of which may account for this patients signs. Findings from the neuro exam should allow you to localize the lesion.

Test Your Clinical Knowledge!

What is the most appropriate liver test to exclude liver cell failure in a routine work-up in elderly patients, especially patients with dementia?

Don't miss: General Surgery Revision Course in RSM this weekend (Sat)

The Royal Society of Medicine near Oxford Road, London is a great resource of learning and clinical development. They have a variety of interesting and very useful revision courses for medical students not to mention a huge range of lectures and talks covering all relevant areas in medicine and surgery running constantly over the year.

I have attended a medical student revision day, which was very helpful indeed. They provide handouts and the speakers are very enthusiastic consultants in London. RSM headquarters is a nice building situated next door to the busy shopping place in Oxford Road. So, you can attend the course and go shopping afterwards!

I highly recommend the surgery course, especially for those of you who are interested in surgery and has finals coming up.

Medics Challenge!

61 year-old lady with a history of Alzheimer’s dementia develops shortness of breath and coughing.

Her husband explains that she became rather vague and unusual during the last 4-5 days; her speech is incoherent with some rambling and irrelevant chatting, which come and go. She also has difficulty focusing and has become very lethargic.

The patient developed pneumonia twice over the last 2-3 weeks. Her past medical history is significant for hypertension and depression for which she takes vals

artan and paroxetine, respectively. She smokes cigarettes and drinks no alcohol.

Bloods for haematology and biochemistry are shown.

What's going on?!!

NB. please note normal values for lab parameters:

Hb (11.7-15.7), MCV(80-99), WBC (3.5-11), Platelets (150-440), Na (135-145), K (3.5-5), Urea (2.5-6.7), Creatinine (70-120). Glucose (4-6), Albumin (35-50), plasma osmolality (275-295), urine osmolality (rang

e; 100-1000).

CLINICAL LESSONS;

1/ be able to differentiate confusion from dementia using CAM

2/ Be able to recognize SIADH - it is suggested by dilutional hyponatraemia with

3/ Be able to categorize the causes of hyponatraemia (dilutional or salt-losing causes)

Perfect Vision Without Surgery

I don't if others with sub-perfect vision feel the same way but I find it really annoying to have to choose between glasses and contact lenses to be able to function in society. Surgical vision correction has its side effects and even though I have family that have undergone the procedure, as an aspiring surgeon, I'm not sure it's a risk I'm willing to take.

Solution? I've come across an old technique that promises perfect 20/20 vision without surgical correction. It's called Orthokeratology (or Ortho-k for short). You wear contact lenses at night that have been custom designed for your eyes. These contact lenses reshape your cornea so that you wake up everyday with perfect vision (kind of like a retainer for the eyes). Unfortunately, this solution only lasts the day.

The only refractive surgery I would consider is insertion of intrastromal corneal ring segments (Intacs), where a new lens is implanted in your eyes. This avoids damage to your cornea and the lens can be changed as your vision changes. As this procedure has only been approved to low degrees of myopia I will have to wait!