An Awful case and pun.

A 70yo woman presents to ED with the following lesions which have been present for 2 weeks now and have steadily progressed from small raised areas into the large, painful areas seen below with moderate amounts of necrosis.

The patient had presented to ED a week earlier and was given a presumptive diagnosis despite the lack of obvious exposure. some antibiotics given for probable secondary infection at that time.

She has no history of major diseases of any kind other than well controlled hypertension (on metoprolol)

 No allergies.


She is a keen gardener who has a pet dog. She has not visited any farms or abattoirs in the recent past.


photo_2   photo_5 photo_4

Further advice was sought from dermatology (email photos sent) which received the following reply:

Thanks for these excellent photos of Orf, probably acquired via contact with a sheep, goat or other animal. Symptomatic management with a topical antiseptic such as Betadine dressings and analgesics is correct.”

Orf is a parapox virus which is passed amongst sheep, goats and a number of other animals (including red squirrels apparently)

It causes lesions like those shown but often much less impressive with papules which often burst releasing purulent (and infective) material.

Most people effected by orf are shearers, farmers and of concern to myself is children with pet lambs.

 kids feeding the lambs

Orf is something that presents reasonably frequently to GP land here in rural(ish) NZ. Many of the people most at risk for orf often treat themselves. Stories of shearers curetting their own lesions abound.

Follow up (2 weeks later)

As you can see most of the lesions have improved significantly with almost complete resolution of some of the later lesions which never ruptured.

photo_4 b photo_3 b photo_1 b

Final  follow-up 8-10 weeks post initial presentation:

I’ve since seen the patient at the supermarket and can confirm complete resolution without any scarring of all of the lesions. She now gardens with gloves on and thinks the only possible exposure was something her dog must have rolled in.

One of the best going cases of Orf I have seen. It can be much more aggressive in those with immunocompromised but as mentioned earlier the patient is very fit and well with no major health issues.

So there you have it one Orful case… *drops mic*

PS. Sorry I Haven’t posted in ages. Will do better in future. :)


The other side of the coin.

I was recently reading the post “Are you really a doctor” from Penny Wilson. This got me thinking about what its like to be on the other side. I’ll get onto my thoughts but first  a story which set the tone for my medical career.

During my 4th year of medical school (first clinical time) on my 2nd day on general medicine.
Post take ward round, desperately trying to keep up with the team as I wasn’t sure which room was which etc.
They were seeing a moderately confused woman in her 80s. The patient had been seen by a female registrar in ED then clerked by the female house surgeon and reviewed by the female registrar.
As I was still trying to find the notes (who hides these!) I was late and missed the consultant reviewing the history and as I nipped through the curtain the female consultant who held not one but two fellowships was examining the patient.
As soon as the patient locked eyes on me she let out a loud sigh and said “thank God! finally I get to see a doctor!” I tried in vain to push the patients attention back to the consultant but was unsuccessful. Each answer the consultant gave was painfully checked with me. Finally after what seems like a lifetime the consultant explained what we would be doing next. the patient replied “If that’s what the doctor thinks is best”

The team took it pretty well and I was the recipient of my fair share of jokes over the run. They had all heard it before but not as clearly as this time.

Very occasionally my gender leads to trouble. I am usually sent to see the trouble makers in ED (fair enough but they are more likely to take a swing at me) I was recently told by a medical protection society worker that a chaperone should be present when listening to female patients heart sounds. They didn’t appreciate “I can understand that when I forget my stethoscope”

Being a bloke leads to the reduction in the number of groping incidents but doesn’t completely stop them. Comments are pretty frequent. Whilst on geriatrics it was considered a pretty accurate assessment of patients frontal lobe status if they suggested my slippers might be welcome under their bed.

I remember hanging out on the labour ward for days trying to get involved with births as people were uncomfortable about a bloke being present. In general practice the split is clearer most women see a female GP for their “women’s issues” I have never had a patient present for a cervical smear (makes a mockery of Fears, Smears and Tears).

And finally I thought I Would finish with a little Margaret  Thatcher.

“If  you want something said, ask a man; if you want something done, ask a  woman.”





Offline resources for remote practice.

 A good friend and mentor who has a few grey hairs carries this with him everywhere.

This contains the distilled wisdom of many years of general practice.

Saw Prof Murtagh had a similar tome from his interview with Gerry over at rural flying doc.


Many pages have fold outs with articles or further information. This portable brain is regularly updated and every few years metamorphoses to a new book dropping some bulk before growing in size again.

He is considering trying an online resource for this next edition but “might be a bit long in the tooth for that”

Anyone else seen a tome of reference or have their own?

A wee ditty for those at #USANZ

Was told this rhyme by an elderly patient today. He learnt it as a boy. This ones for the urologists.


“When a man grows old and his balls turn cold,

and the end of his prick turns blue,

and the hole in the middle refuses to piddle,

I’d say he’s stuffed wouldn’t you?”




Thoughts on Poker and Medicine

While listening to Simon Carley on risk at #SMACC2013 I had one of those thoughts.

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First I hope any serious poker players can forgive my over simplifications of a wonderful game. I also hope everyone can forgive my extreme stretching of this metaphor.


So why is medicine like a poker game?
It’s about prediction and probabilities, sometimes we are accurate and can be quite sure of ourselves but sometimes we get caught out by a surprise card or unlikely diagnosis.

In emergency medicine we often concern ourselves with the dangerous diagnoses, most poker players consider these options and likelihood their opponent will draw them. If you have played against a person/disease many times you can be more confident that you will be able to  judge their strength or recognise their tells.

In both luck plays a role that both doctors and card players are uncomfortable with. Everyone will have a “bad beat” where you are confident that you have the correct response or reaction but something unlikely/rare happens and you lose. This leads to both groups having superstitions and sayings which are similar.

“You play the man not his cards” sounds a lot like “It matters more which patient has the disease than which disease the patient has”

Like poker, medicine can be played at a number of stakes. Is it a life and death situation or just trying to rid someone of a minor irritation.

Texas Holdem

Medicine is most like Texas holdem (heads up).
I’ll explain why with an explanation of how it’s played and the similarities.

Heads up poker is played against one other person. You have your own cards and there are a number of communal cards which you make your best hand from. In this way a poker hand reflects a medical consultation information is slowly revealed and you attempt to gauge your position and certainty.

The rounds are as follows:

Pocket cards:

File:Pair of Aces.jpg

Firstly you are given two cards, an initial impression. You know from a glance if this patient is sick or not. Your system 1 is firing on all cylinders. You may get an instant diagnosis from the end of the bed, ?pocket Aces.

But you also know when you don’t have an idea. You know it will be hard or perhaps you just don’t want to play this hand.

Everyone makes their bets, some times this is easy. The patient is dry start some fluids, pain relief/Raise. Other times you don’t want to initiate much treatment until you have more information/Check.
In medicine you can’t really fold. unless you take the next chart (don’t be this person).

 The flop:

Three cards are turned over. This equates well with the history, it’s where the money is. Based on what you know about the patient and you impression most times you can have a very good idea about how you are placed. But there is some difficulty. Many diseases are difficult to tease out, are you being bluffed by your opponent. Previous experience with the opponent/disease can help you here. Are they likely to play passively or do they often show their strength?

The Turn:

This is the physical exam. (might be giving too much credit here)

This adds to what has come before. The reaction to this, tells/focal signs often increase your confidence in your diagnosis. But again it can leave you feeling unsure. But often it makes minimal difference, your impression can remain unchanged based on presence or absence of some signs. This is also often when you take a little time to think of any other possibilities you may have forgotten, a few extra questions whilst examining.

 The River:

 The investigations. Everything is back, all the information you are going to get is there.

This confirms or refutes your previous thoughts. You often know where you stand are you “the nuts” ?

But everything can change and swing based on one investigation/the final card. Is the bloody D-dimer positive? 

Then the final rounds of betting, are you all in for one diagnosis or are you still unsure of yourself? Often you know your badly placed (Pt is sick) but you can’t be certain of why.

 Finally the hands are revealed; in medicine like in poker you may never find out if you were right. Your opponent may never reveal their cards.

The best you can hope for is to learn from your mistakes, minimise your losses and be ready to play again.

But remember, in the end the house always wins.