Archives for October 2012

Dealing with difficult patients.

 We often have patients who are a little more worried about their standards of care than others. They often want some sort of commitment from you that you are going to do your best or that you are the right person to be treating them. I often find myself telling these patients, you know the rules and so do I. A full commitment’s what I’m thinking of, You wouldnt get this from any other doc. I just wanna tell you how I’m feeling, Gotta make you understand… Never gonna give you up, Never gonna let you down, Never gonna run around and desert you. Never gonna make you cry, Never gonna say goodbye, Never gonna tell a lie and hurt you. #RickRolled =)

Sorry thats what a friday afternoon does to my brain. hope you have a good weekend. I’m off to PRIME so will report back on that next week.

Left, Right, Out.

Lovely 82 Y/O woman with B/G of CHF with reasonable control came in with worsening breathlessness.

No orthopnoea/PND but greatly decreased exercise tolerance. “couldn’t to the gardening anymore.” No infective symptoms. No wheeze, never smoked.

Exam showed, JVP not elevated, Good AE Right, But L basal dullness. had medical student who was very excited by the “stony dull” nature. CXR showed:

Discussed with the consultant who felt that effusion is likely related to patients CHF. We had a discussion about unilateral pleural effusions in CHF. Now the teaching is yes it happens, but more often on the right. As was left sided needed to be tapped to rule out other causes. we agreed that would likely tap similar on the right for symptomatic benefit.

So I like doing chest drains/tubes. In this case I used the USS to X marks my spot with a sharpie, Local, Seldinger small tube.

Satisfying result. Clamped after 500ml for bout an hour, same again then left to drain remaining. Now not sure of evidence for this but just what staff like here. *Bows to charge nurse*

Looks a bit redder in the photo than RL.

Analysis of the fluid showed a transudate. Sent 3 samples to be spun for cells. all negative for malignant cells. Normal LFTS and electrolytes. So was happy with cause.

Follow up CXR, was good. patient returned home following day. No recurrence of effusion at clinic 2 weeks later.

Got me thinking, and thinking leads to searching which lead me to a couple of good articles. Dr Woodring did a nice simple study of 120 consecutive patients with clinical diagnosis of CHF and CXR effusion or effusions. Which found no differences in rates of unilateral effusions being on either right or left.

But “nobody expects the Spanish Inquisition!” or Dr’s Porcel and Vives who  pooled the data from their institution (in Spain) into a much larger case series confirming the old studies with about a 2:1 predominance.

Seems the old teaching is correct about occurrence. Still I am not certain I would be happy calling a right sided effusion pure CHF without some fluid analysis..

Links to those studies.

Dr Woodring

Spainish Inquision.