"Monospots are rubbish"

We've had a run of patients with large neck glands (cervical lymphadenitis) in lately. The first, a 16 year-old who presented with a sore throat and dehydration, had obvious glandular fever. Her glands were so large, her chin had nearly disappeared into her neck. The tonsils were red with exudate, and her liver and spleen were enlarged. Her lymphocyte count was 26. She had a positive monospot (unsurprisingly).
Last night's crop of new patients included a 7 year-old with a left-sided painful neck swelling and an 8-month old with a non-tender 2cm neck lump. Both patients had had monospots sent, to which the consultant said "but monospots are rubbish anyway." So I thought I'd look up exactly how rubbish they are.

I found this on Medscape:

its sensitivity is only 20% in young children. This test is frequently used to assess EBV infection in older children (>5 years-old). It is easy to perform and has a sensitivity of 85% in older children and a specificity of 97% (Peter & Ray, 1998).

here's a more complete answer
ok now i'm bored.

Notes 1

4 day old; unbooked/concealed pregnancy; both parents IVDUs known to social work; NAS on oramorph
reading: associations with maternal drug use: defects including cardiac (esp cocaine), abdominal wall (these associated with SGA baby/placental insufficiency); polycythaemia and increased risk of neonatal thrombosis;
7 month old; bronchiolitis. Both parents smokers.
reading: associations of paediatric respiratory disease with maternal (fewer data available on fathers) smoking; increased incidence of URTI and LRTI including otitis media, pneumonia; risk factor for asthma development

[note confounding factors: J Am Board Fam Pract 14(5):330-334, 2001 - mothers who smoked during pregnancy likely to be younger, and have smaller babies of shorter gestational age; I'd guess they would be of a lower social class also.]

Note the former baby's future does not look particularly bright. But that is another story for another time.

Chatted with Prof I met at conference - advice on how to proceed re: getting into some Proper research. Also with sensible consultant on for Receiving this week, which makes a big difference. Am liking work more this week.

Fed up already

I've never hated work quite so much. Two days back at work, and all I am looking forward to is my next day off. Am hoping it is just the fact that this is Acute Receiving, and I chose the placement specifically because I have less experience in the area, hate resuscitations and the aim was to get it out of the way. But I'm hating it even more than I thought it would. I hate how patients come through, you fix them if you can, refer them on if you can't, and then you never see them again. i.e. there's no continuity; the patients never feel like your patients; it's all just really fragmented and everything takes twice as long because it's impossible to know all the patients. And everyone else seems to be off sick all the time - I acceded to a "request" to cover someone's evening shift yesterday. But I really really wanted to say 'no'.

So I've booked myself a place at a research conference. I hope it's good. Am desperate at the moment for some inspiration; something to remind me that there is more to medicine than unthinking drudgery and ungratefulness from all sides. Otherwise it will be time to start plotting a way out.

A short break in Barcelona

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The Toast Sign

The first time I came across the Toast Sign, I didn't recognise it. I was a medical student on the labour ward, fascinated by the sight of nursing auxillaries scurrying about with trays of Tea-and-Toast - only for the mothers who had already given birth, of course.

On call yesterday at A&E, I was asked to see an 8 month-old boy who had come in with vomiting so severe, the A&E doctors thought he might have intussusception. As I approached the curtained cubicle, I heard little crunching noises. Behind the curtain was a pink and rather cheery-looking baby, chewing on some dry toast with his brand new teeth. "He's miles better since they gave him that fluid through the drip," said his mother. "He's back to his normal self," added father. I sent him home with a diagnosis of gastroenteritis.

Fluid balance charts on childrens' wards can often be quite informative. For instance, one of the more bizarre but common breakfast choices on our ward is a packet of Quavers . But you can be sure your patient is very nearly well enough to go home if they've had toast. Especially if they were admitted with tonsillitis. But it also works for patients with pneumonia or even orbital cellulitis. I think I might be on to something. Christmas BMJ here I come.