Chickpeas and black pudding

Youee and I made a birthday cake for Ching! A shameless fusion of two Nigella Lawson recipes, it tasted somewhat better than what Youee thought the book's illustration was.

A piece of medical history

Fascinating article in the Observer Woman magazine today about Carl Djerassi, the inventor of the Pill.

I took the official 'bride getting ready' shots for T&R's wedding yesterday. Here's a selection: (just a few of about 120)

not having a fit

“Call for you,” said the switchboard operator, in her usual drone. “Hi, this is Mrs. Berkenstein*,” a shrill voice with a decidedly Germanic accent crackled down the line. “I’m *Nathaniel’s mother. Is this *Sally?” “No, it’s Sam, I said,” rather taken aback at being bleeped before 9 in the morning on my first day as Paediatric Neurology SHO by a patient’s mother. Nathaniel is a 6 month-old boy with infantile spasms. His mother had phoned for a repeat prescription – steroids, ranitidine and pyridoxine. She said Sally (the previous person who was in my job) used to fax the prescription to her local pharmacist.

Before I’d had the chance to sort out her request (and right in the middle of clinic), I had another call from a mother: “*Jacob’s school has sent him home because he was going blue around the mouth and rolling his eyes to one side. We saw Dr. *Ahmed last Tuesday and he increased Jacob’s medicines but he is fitting more now. We don’t want to come into hospital again, what do you advise?” I asked her some further questions, but it was impossible to assess the child without actually seeing him. I explained this to her, but she was adamant; “the team have always given advice over the phone in the past,” she insisted, before admitting that the current situation was a new one. I guess one of the luxuries of being a junior doctor is that when you have your back to the wall, you can always wriggle your way out by saying you’ll speak to your consultant and get back to the patient.

Jacob eventually came into hospital and an EEG confirmed increased seizure activity. A blood gas showed a partially compensated metabolic acidosis – in his case it could be due either to the ketogenic diet or intercurrent infection, so we started him on antibiotics and sodium bicarbonate.

Quite apart from all I was learning about seizure disorders, it was interesting to meet these mothers in person. Both were petite Orthodox Jewish ladies, dressed in the usual garb of loose, dark-coloured long-sleeved blouse and black below-knee skirt, dark tights, chunky black loafers and a hat or headscarf worn at all times. Beneath all that, they looked impossibly young (I’d estimate early twenties, certainly significantly younger than myself) and vulnerable. Speaking face to face with them was absolutely fine – they were both gracious and articulate, and though understandably concerned about their sons, were by no means overly anxious or unreasonable. Perhaps the scary telephone persona was a kind of “take me seriously or else” act.

all change

Am quite liking my new job - we had clinic all day on tuesday, and I saw (and made decisions about) patients with conditions ranging from the commonplace (migraine without aura, suspected absence seizures) to the exceedingly rare (cat eye syndrome, mitochondrial electron chain complex 4 deficiency). Nearly lost my voice dictating all the clinic letters afterwards. Today was slightly duller - 5 patients on the ward round, a psychosocial meeting, and having to grapple with really stupid computer-programmed theatre lists that won't let you put a patient on the list who does not have a surgeon for a consultant. Whoever designed it didn't figure that there are other reasons to have an anaesthetic apart from surgery. Have to be in at 08:00 tomorrow to clerk in the patients for lumbar punctures and manometry under general anaesthetic. Should be interesting to do though. Not inspired enough to blog properly about individual patients at present.

diagnosis? (or, I'm not feeling so good)

Just to catalogue my symptoms so far:

-lethargy, malaise and ?depression - about 3 months
-pain in both calves - 14 days ago, for 3 days, resolving spontaneously
-generalised myopathy and ?rigors- 10 days ago, for about 3 days, resolving spontaneously
-leucopenia (neutrophils 1.6, lymphocytes 0.60); Hb 13, but i'm on a multivitamin with iron in it
-raised d-dimers (exact level not known to me)
-morbiliform rash all over body, including palms, soles and face, with mild bilateral conjunctivitis - 7 days ago, for about 3 days, resolving spontaneously (slightly itchy, resolving with cetirizine)
-lymphadenopathy, mainly cervical (smooth mobile nodes about 2cm) - last 7 days
-pain, stiffness and swelling in joints - small joints of hands and feet, both ankles, both wrists and both knees. stiffness for about an hour in the mornings, difficulty walking and turning doorknobs - last 3 days, worst today

Differential diagnosis:
1. viral infection - possible viruses include parvovirus B19, EBV (common, fits all symptoms and I am at risk due to occupational exposure to lots of children)
2. rheumatoid arthritis (but is not associated with rash, also peak age of onset = 5th decade); or other connective tissue disease
3. hypothyroidism (also not associated with rash, but could explain all other symptoms and is commoner in females)
4. lymphoma (unlikely due to leucopenia and normal blood film, but peak age of incidence =3rd decade)

Therefore if the symptoms continue after next week, I suppose I should get someone to take blood from me for
-repeat FBC and film, U&Es. LFTs, TFTs, ESR, CRP, ANA. antidsDNA and rheumatoid factor
The question is how soon to do them. Maybe I'll give it 4 to 6 weeks.
Meanwhile I shall be taking ibuprofen regularly.

The GP didn't do much for me apart from providing a sick note. I had hoped he would at least examine my joints, but he didn't seem interested. He also didn't seem to know that parvovirus infection can cause raised autoantibodies and ESR (and therefore those tests would be completely useless at distinguishing between 1. and 2. at this point). I think I might feel better if I could just stop being (my own) doctor for 30 minutes.