Tuesday, 16 October 2007


Fat Doctor recently reported that medical knowledge doubles every two years. I use that as a faint excuse while describing an area of my ignorance that recently came to light.

A fortnight ago I saw a young woman who consulted me about a number of problems. As she was leaving she mentioned that she had experienced some pains in her elbows and knees the previous week after doing some dives with her boyfriend on holiday. I thought that they might have been linked with her diving, but as they were now settling there seemed little to be done. A little research after she had gone confirmed my suspicion that they were due to the “bends” but again I didn't think it necessary to take any action.

She came to see me again today. The pains had continued and she had rung NHS Direct for advice who, she told me, were useless. She kindly forbore to say that I was useless too. So she had done some research on the internet and found a medical diving centre in London who offer NHS-funded treatment. She had gone to London to see the doctor, who had found some neurological signs and given her six hours in the recompression chamber. All was now well.

I felt uneasy because not only had I failed to recognise the necessity of treating her bends because the symptoms were mild and apparently settling, but I wouldn't have known where to send her if I had. The reason she had come to see me was that the centre doctor thought that she was unusually prone to the bends, for her boyfriend had done the same dives with no problems, and was interested in the fact that she suffers from migraine with aura. There is a cardiovascular abnormality associated with these two conditions which again I was not aware of. No doubt the brilliant medical students who read this blog will have the facts at their fingertips.

I suppose that I should not flagellate myself too much. Divers really ought to know about the symptoms of the bends, and what to do if they occur. And perhaps what I said to her at the initial consultation made her think about the diagnosis and do her research. She seemed not to bear me any ill will. I examined her cardiovascular system and found no abnormality, and have now referred her for cardiological assessment.

I was on surer ground when I saw a lad of ten. He is the grandson of an eminent local consultant, which always makes me slightly nervous, but he and his mother are both charming. He had suffered from one-sided headache and earache for a few days, and then come out in a rash on the (same) side of his neck last night. His mother had spoken to a friend of hers, who is a GP and suggested shingles as the diagnosis. By this morning that diagnosis was obviously correct; there were a number of red patches with numerous small blisters on the side of his neck and coming down onto the front of his chest. I can never remember where the dermatomes are and always have to look in a book, in his case it was the C3 distribution.

Aciclovir and analgesia are what is needed, and I checked the dose of aciclovir for his age in the BNF. I also printed off a leaflet and had a talk with him and his mother. I thought I had covered everything, but patients will always find something to ask that you hadn't thought of. In this case his mother wanted to know if the rash would spread elsewhere on the body, to which the answer was “no”, and would it affect his eyes? This had been suggested by her GP friend last night. However, corneal involvement only occurs when shingles affects the ophthalmic branch of the fifth cranial nerve. The third cervical root goes nowhere near the eye, so I was able to reassure her.


The Shrink said...

Divers really ought to know about the symptoms of the bends, and what to do if they occur.


It was drilled in to my wife and me when we did our initial PADI and advanced diving courses, anyone diving should be aware of the symptoms and signs and management options.

Shingles in a 10 year old, is it common to get reactivation and clinical shingles in kiddies? Okay, it's only bad cases I see in secondary care when neuropathic pain's an issue, but invariably it's folks in their 50's and upwards.

Anonymous said...

I'm a medical student and a long time lurking reader; today I'm reading to take my mind off learning the dermatomes, and it's beautifully reassuring to hear you don't know them either ;)

Ms Medic said...

I have never heard of the syndrome you describe, despite having read lots about stuff associated with migranes (being a sufferer myself). Now I almost feel as if I should! Something else tells me it won't come up in finals and I should re-learn all the basics I forgot in my BSc year instead! I have a feeling you know a lot more about everything than your devoted student readers.

Dr Andrew Brown said...

The Shrink: Thanks for the support. And I agree that shingles is more common in older adults, but it can occasionally occur in children. I can't remember the last time I saw a case, however.

Anonymous: I'm glad you enjoy the blog (either that or you have masochistic tendencies). I learned the dermatomes once, long ago, but I don't use them often enough in my clinical work to have them at my fingertips. Outside exams, it's OK not to remember everything as long as you know where to find the information. And I think it impresses the patients to take a big book off the shelf and show them what is happening.

Ms Medic: It's kind of you to suspect me of great knowledge, and who am I to disabuse you? :-)

In one way, learning gets easier as you get older and more experienced, because you have a comprehensive range of existing knowledge into which to slot the new stuff. This compensates a little for the hardening of the arteries, or so I like to believe.

medstudentitis said...

I thought it was a PFO that's associated with both migraines and the bends... so I guess an echo would show it?

Dr Andrew Brown said...

Medstudentitis: that's the one! (Patent foramen ovale.)