Clinical Dialogues in Hospital Medicine: A True Representation of Classic Ward Round Proceedings

By Gabriel C Ukala, FRCP Edin

Clinical Dialogues in Hospital Medicine – a true representation of classic ward round proceedings, is an exciting, novel approach to medical writing showcasing “speaking/teaching” from the bedside. It is written in such elegant style that makes for easy reading using real patients encountered in ward rounds over the years and designed as a clinical companion to medical students studying Internal Medicine around the world as well as a refreshing read for clinicians. It includes over 60 pages of example-based guides to ECG interpretation.

• Language: English
• Publisher: BookBaby
• Release date: Feb 6, 2015
• ISBN: 9781483550145

Book preview

legislation.

Contents

Foreword

PREFACE

Acknowledgements

LIST OF ABBREVIATIONS

INTRODUCTION

MASTERING THE NUANCES OF MEDICAL HISTORY TAKING

Case #1

Case #2

Case #3

Case #4

Case #5

Case #6

Case #7

Case #8

Case #9

Case #10

Case #11

Case #12

Case #13

Case #14

Case #15

Case #16

Case #17

Case #18

Case #19

Case #20

Case #21

Case #22

Case #23

Case #24

Case #25

Case #26

CLINICAL LABORATORY TESTS – NORMAL VALUES²⁴⁷

References

About the Author

Index

Foreword

Clinical Dialogues in Hospital Medicine is an excellent collection of cases seen over time on the wards of the Department of Internal Medicine at the Mandeville Regional Hospital and Dr Ukala must be commended for his foresight, patience and diligence in compiling them. The narrative accompanying each case is simple and has appropriate illustrations which makes for easy reading. There is an impressive list of references underscoring the tremendous work that has gone into the preparation of this manuscript.

This will be very useful to final year medical students, interns and residents in training in Internal Medicine as well as doctors in general practice who have an interest in updating their skills.

– Dr Hopeton G. St. C. Falconer, MBBS, MSc (Immunology), DM (Internal Medicine): Chief Editor. Consultant Physician, former head of Internal Medicine and past Senior Medical Officer of the Mandeville Regional Hospital.

_________________

Dr Gabriel Ukala’s Clinical Dialogues in Hospital Medicine is well researched and well written. A practical, principled and purposeful approach is outlined in the diagnosis and management of common presenting medical conditions, especially those of cardiovascular origin. The section on interpretation of ECGs is a very timely and practical guide.

This book (with some inspiring quotations), which is a novel approach, simple to read and exciting, reveals Dr Ukala’s passion for medicine; and will be of great benefit to medical students and physicians involved not only in hospital medicine but also in office practice.

– Dr Daive R Facey, MD (Hons.): Family Physician and Winner of the Jamaica Gleaner October 2013 Silver Pen Award for excellent penmanship.

Dr. Ukala examines a chest radiograph

PREFACE

Clinical Dialogues in Hospital Medicine is not a standard medical text; it is not a book of lecture notes in medicine; and it is not a hard-core question and answer text for exam preparations in medicine. It is, simply, a representation of typical ward round proceedings – often a lively, case by case, freely-flowing bedside conversations between the consultant and his team of medical students and other doctors; only, this time, meticulously researched to reflect current trends and evidence-based practice. Bedside dialogues remain the stuff that learning and mentoring in medicine is made of.

This is the first step in what is hoped to be an endless series or editions in generations to come – as the possibility for adding new and exciting cases from time to time will never cease.

Dr. Ukala with patients in the reception area waiting to be seen

Acknowledgements

I am deeply grateful to a great number of persons who helped, in so many different ways, to define who I have become over the years but, specifically, those who contributed to the realization of this book.

First, my darling wife, Dr Sonia Reid-Ukala: who relentlessly sees in me that to which my blindness is profound – an immense potential to reach the stars and be whatever I want to be. In doing so, she constantly deprives herself and continues to make sacrifices to help me further along my path. Through the process of writing this book, she was like my own wine-taster who read through every script as they hatched and offered immeasurable advice.

My two lovely and dearly loved daughters: Ezinne and Osezim, whose understanding and support are beyond description. Through the many years and endless hours of writing this book, they endured my rather frequent absence at their playground, school trips, homework sessions, and so on. But their encouragement was unwavering. Osy repeatedly threatened me to never give up on the book so she can earn a well-deserved commission and Ezy did the fine artwork on the front cover by herself – and on completion she said, See, Daddy, I’ve done the cover page; now, you must finish the book!

The patients whose stories I have told in this book: though they may not know it, the seriousness of their unfortunate afflictions and, sometimes, demise warranted further in-depth research and discussions to enable us treat them better.

My key Residents: Dr Ryan Gregory, Dr Myintzu Aung, Dr Sarah Aljohar and Dr Chanique James who were instrumental in many ways to the realization of this book. Dr Gregory was my designated photographer who endured my constant harassment for more clinical pictures.

Dr Peter Wellington, FRCS and Dr Hopeton G. St. C. Falconer, MBBS, MSc (Immunology), DM (INT. MED): both past Senior Medical Officers of the Mandeville Regional Hospital, who believed in me, stood by me, nurtured and supported me through my MRCP training in the United Kingdom. If a second and third father were possible, they would be both these men. Moreover, as if he has not done enough, Dr Falconer, my Internal Medicine mentor, agreed to edit this book with such patience, love and passion – attributes for which he is well known.

Dr Juliet Wynter-Daley MB, BS, DM: Senior Consultant Physician and Pulmonologist at the Mandeville Regional Hospital, whose very sharp and critical mind as well as her in-depth approach to patient care continue to influence my professional performances; looking up to her, constantly brings out the best in me.

The Radiologists: Dr Phil Chamberlain (of blessed memory), Dr Marlene Craigie and Dr Alistair McBean all of who provided me with various images of my patients and assisted me with their interpretation.

Dr Ashok Jacob, Consultant Cardiologist, St. John’s Hospital, West Lothian, Livinsgton, Scotland: whose kindness, alacrity of mind and passion for cardiology ignited my interest in Internal Medicine in general and cardiology specifically. I owe my success at the MRCP PACES examination in 2004 to the congenial work and study environment he provided for me.

Professor Everard Barton BSc (Hons) MBBS (Ibadan) DM (UWI) FACP, FRCP (Ed) O.D., a most outstanding internationally acclaimed, compassionate and highly respected professor of medicine and nephrology: always quietly encouraging and seeking to elevate anyone who dares to be extraordinary. My professional career and status would not be where it is without his kindness.

Dr Owen Bancroft O’Leary James, O.D. MB.ChB. (Edin), Clinician and Microbiologist: One of the finest jewels in our medical fraternity; an academician to the core, comedian, mouth organist (at the time) and Dean of the All American Institute of Medical Sciences, Black River, Jamaica, who (unknown to him) influenced my choice of Edinburgh for my MRCP experience. I am deeply honoured and eternally grateful to him for accepting to review this book.

Dr Daive R. Facey M.D. (Hons): an excellent general practitioner, musician, powerful writer and social commentator; winner of the 2013 Jamaica Gleaner Silver pen award for excellent penmanship, and a friend, who relentlessly encouraged me, over the years, to write. I am immensely grateful to him for reviewing this book and offering countless pieces of advice.

Drs Patrick Eyiche Adizua and Leslane Cameron-Adizua: without who choosing to live in Jamaica would have been difficult. Their open-hearted kindness, love, support and encouragement have made this journey worthwhile. I cannot thank them enough.

My dear secretary: Paulette Powell-Hamm, who kept my offices going while I studied and who’s standard of service, understanding and sacrifice for many, many years can neither be truly quantified nor adequately compensated.

The Ukala family: Mr Godwin Njoaguali Ukala & Mrs Beatrice Nwoji Ukala – my parents of blessed memory (both of whom had little or no formal education); whose vision and commitment to give their seven children the best education there was at the time changed the landscape of parenthood in their community resulting in the following: Dr Grace Williams, Professor Sam Ukala, Professor Mercy Anyiwe, Dr Engineer Reverend Gladys Nwosah, Barrister & Pro Chancellor Emmanuel Ukala Esq. SAN, Dr Gabriel Ukala FRCP Edin and Mrs Ngozi J Bamah – a postgraduate qualified School Principal. My siblings’ love continues to sustain me and their various achievements define such great excellence that keeps pushing the bar of my expectations higher and higher.

Finally and most importantly, God: that ocean of love and mercy from which all wisdom flows; Its essence planted all of these people (and many more) in my path to help me along.

I am eternally grateful.

Dr Gabriel C. Ukala, FRCP Edin.

November 2013

LIST OF ABBREVIATIONS

INTRODUCTION

CLINICAL DIALOGUES IN HOSPITAL MEDICINE

Not all of us can do great things. But we can do small things with great love.

– Mother Teresa

Clinical ward rounds remain an essential tool in the management of hospital in-patients as well as in the on-going development and learning experience for the attending physician and junior doctors alike. Equally important, is the role of ward rounds in the teaching of medical students, whether they are at the undergraduate or post-graduate level without compromising patient care, privacy or dignity.

A well conducted medical ward round emphasizes the importance of role models in clinical skill acquisition. Post-take rounds, on the other hand, give you the chance to see acute presentations and the first line management of many medical conditions. This learning experience can be priceless for medical students as it offers a great opportunity to improve their history-taking skills, practice examination of patients and develop the crucial ability in clinical problem-solving.

Whilst ward rounds of today continue to cover management of patients adequately, there is increasing demand by trainees for more to be done by the attending physician in the aspects of bedside examinations, clinical skills teaching, communication skills, counselling and medical ethics.¹

Internal Medicine is the bedrock of medical practice covering a broad scope of subspecialties such as cardiology, endocrinology, gastroenterology, infectious diseases, nephrology, neurology and pulmonology, to mention a few. The American College of Physicians defines Internal medicine physicians as Specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.² This depth of scientific knowledge and clinical expertise is expected to be demonstrated at all times during ward rounds when vital management decisions are taken.

It is not surprising, therefore, that consultant ward rounds can sometimes be nerve-wracking for all participants, as one never knows what case(s) may present next.

No one will ever know everything but a successful and productive ward round will always be a product of the application of the right attitudes, ability to work from first principles and an acute awareness and constant reminding of oneself of the relevant facts – both from standard text and the ever evolving new material found in medical journals.

This book, which turned out to be such a Herculean task, is a product of my passion for attending medical ward rounds and teaching junior doctors and medical students over the years. The dialogues between the attending physician and his team in trying to understand and unravel a patient’s presenting condition and attempt to figure out a management plan can be very challenging and informative. It is rewarding to see the faces of your junior colleagues light up when you impart relevant knowledge or demonstrate how a clinical skill is performed. It is also rewarding to see the frown of disagreement when you slip and make statements that are, well, not so accurate – because you then get an opportunity to re-educate yourself on that subject matter. For me, every teaching round is a win-win situation.

One of the objectives of this book is to provide quick and easy access to commonly sought-after facts about general medical conditions encountered on the wards during ward rounds. All of the materials presented here-in are based on real patients encountered over the years and, since the pool of interesting clinical cases will always be inexhaustible, what is recorded here reflects only the tip of the iceberg.

The format adopted here assumes that patients are admitted into general medical wards, not separated by sub-specialties. This makes it much more interesting and unpredictable, so that at the end of a typical ward round one would have covered a mix of all the subspecialties including cardiology, rheumatology, nephrology, pulmonology, neurology, to mention a few. In each case, an attempt is made to discuss the academic and sometimes evidence-based reasons behind the choice of management. As a result, each case has been painstakingly referenced to reflect current and international standards. No medical writer can complete a credible article or any useful text without referring to or borrowing information from existing literature on the subject matter. I have done exactly the same while taking great pains to give credit to all my sources. Any lapses to this end are unintentional.

These presentations are intended to represent typical ward round proceedings with questions being followed immediately by answers and, not surprisingly, the emphasis is on recognition and management of these conditions rather than basic science and pathophysiology. The intended targets of this book are not just medical students. While not being exhaustive or in-depth enough to replace any existing medical text, it should potentially act as an additional resource for anyone involved in the management of medical patients as well as those teaching medicine at any level.

It is an addition to existing medical literature from my own perspective. This, indeed, is my little deed for medicine, with great love!

Happy reading.

MASTERING THE NUANCES OF MEDICAL HISTORY TAKING

Successful evaluation of a patient’s condition begins with the taking of an accurate history. In about 70% cases, a correct diagnosis can be made from history alone. ³ While a great deal of knowledge may not be an absolute requisite for obtaining a good history from a patient, a fair understanding of disease processes and pathophysiology is often needed to be able to ask logical and relevant questions. A good doctor is for the most part a good listener because he or she knows that hidden somewhere in what the patient says is a clue to the diagnosis. All it takes is the ability to listen and ask simple, logical and sometimes common sense questions.

Always remember that somewhere in the patient’s story lies the key to the diagnosis.

The Fundamentals of History Taking

Generally all history taken from patients, irrespective of the discipline, should contain the following information:

1. Presenting complaint

2. History of the presenting complaint

3. Past medical history

4. Family history

5. Social history

6. Drug history

7. History of allergies

8. Systemic inquiry or Review of systems

Other specific pieces of information that must be included are:

• Reproductive history (if patient is a female of reproductive age; examples of the information sought may include menstrual history, parity, use of oral contraception and gynaecological history).

• Pregnancy, birth and developmental history in case of paediatric patients.

How to Begin Taking a History

The more experienced you are the easier it becomes to have a sense of what is relevant information to extract from your patient.

• First, introduce yourself. It’s important that the patient (and relatives) actually hears your name clearly!

• Confirm the patient’s name (and remember it!) while offering your greetings in a friendly and relaxed manner. Make the patient comfortable and ensure the interview is in the right setting as much as possible. Always ensure privacy.

• You must look respectful and trustworthy, as confidentiality is of utmost importance.

• Once the patient feels comfortable to begin, record personal details (always), such as:

o Name

o Sex

o Date of birth/age

o Address

o Ethnicity

o Occupation

o Religion (some religious groups do not accept certain types of treatment such as blood transfusions; it’s worthwhile knowing from the start)

o Marital status, and

o Date of examination

• Also record the next of kin and telephone numbers where possible

• Now recall those fundamentals of history taking as stated above

• Make an effort to see things from the patient’s point of view so as to understand their anxiety but, at the same time, maintain a neutral position.³

• Be a good listener

• When you do