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.