ARTERITIS de la TEMPORAL. Caso clínico presentado por Nora Palomo (R1)

* Varón de 87 años
* Antecedentes Personales: HTA, DM de tipo 2, ACxFA permanente. Glaucoma. Neuritis óptica isquémica tras episodio de Amaurosis Fugaz hace 1 mes. IQ: Cataratas, Hernia inguinal.
* Tto. habitual: Sintrom; Lisinopril/Hidroclorotiazida 20/12.5 (1-0-0); Xalatán Colirio (0-0-1).
* Motivo de Consulta: Sd. Constitucional y alteración del ánimo de un mes de evolución.
* Anamnesis: Refiere cefalea bitemporal acompañada de astenia, anorexia y adelgazamiento (pérdida de 8 kg en el último mes) de un mes de evolución. Cuenta también claudicación mandibular.
* Exploración física: TA 131/61mmHg FC 96lpm  Tª36ºC  SatO2 96%. Buen estado general. Consciente y orientado. Bien hidratado y perfundido. Normocoloreado. Eupneico. Afebril. CyC: Dudoso soplo carotideo izdo. No se palpan adenopatías laterocervicales. Orofaringe: Normal. AC: Arrítmica, sin soplos. AP: Murmullo vesicular conservado en ambos campos pulmonares, sin ruidos sobreañadidos. ABD: Blando y depresible. No doloroso a la palpación. No palpo masas ni megalias. No signos de irritación peritoneal. PPRB negativa. EEII: No edemas. No signos de TVP
* Pruebas complementarias: - EKG: ACxFA a 95lpm, extrasístoles ventriculares.- Analítica: Sin alteraciones, salvo: PCR 107; VSG(1ªh) 71.- TAC craneal: Normal.- TAC abdomino-pélvico: Sin lesiones sugestivas de malignidad.- ECO doppler cervical: Placa de ateromatósis en carótida izda.- RX torax: Aumento del botón aórtico. Cardiomegalia.
* Diagnóstico de presunción:- Arteritis de la Temporal
* Tratamiento:- Corticoides a dosis elevadas y posterior pauta descendente. - Bifosfonatos. -Se deriva a Consultas Externas de Reumatología para control del tratamiento.
* Evolución:- Tras inicio de tratamiento corticoideo, el paciente se encuentra mejor: La astenia ha desaparecido, ha ganado peso, no cefalea ni dolor mandibular.- Analíticamente, normalización de PCR y VSG.
* Diagnóstico final: ARTERITIS DE LA TEMPORAL


Señala los motivos por los cuales has elegido presentar este caso clínico (caso de difícil diagnóstico, problema social,…):-1) Caso interesante en el que es necesario relacionar y englobar toda la sintomatología para poder llegar a un diagnóstico final correcto.-2) La importancia de realizar el diagnóstico lo antes posible para asegurar un tratamiento precoz y evitar que la enfermedad evolucione.

Inferior and Posterior STEMI. What else?

A male in his late 30's to early 40's presented with 24 hours of intermittent typical chest pain.  The following ECG was recorded:
There is an obvious acute inferior STEMI.  The inferior Q-waves suggest that there is an old inferior MI or that this one is subacute, but an old ECG was available and also had similar Q-waves..  There is also ST depression in V2 and V3, also minimal in V4-V6.  This is posterior injury, which frequently is simultaneous with inferior injury. There are also large R-waves in V2 and V3, which could represent infarction of the posterior wall.                                                                                                                     There is one other interesting finding.

There is some STE in lead V1.  There should be some ST depression in V1 corresponding to the posterior injury.  Whenever there is inferior STEMI, one should think about Right Ventricular STEMI (RVMI).  RV MI can only occur with RCA occlusion, as the RV marginal branches off the RCA.  As 85% of inferior STEMI are due to RCA occlusion [the rest due to occlusion of a "dominant" circumflex (i.e., it supplies the inferior wall)], one must frequently consider RV MI.  RCA occlusion usually has reciprocal ST depression in lead I (all inferior STEMI have reciprocal ST depression in aVL!) and STE in lead III > STE in lead II.

When there is RV MI, there is almost always some ST elevation in lead V1.  And if there is ST elevation in lead V1, one must consider RV MI.  This STE in V1 prompted recording of a right sided ECG:

Leads V1 and V2 were not reversed as they should be in a right side recording, so V1=V1 (not V1R) and V2 = V2 (not V2R):
V1 now has much more ST elevation (the STEMI has progressed, which one can also see in the inferior leads).  V2 has less ST depression than before, probably because right ventricular injury is "pulling the ST segment up".  There is profound STE in V3R to V6R

Right ventricular infarct is associated with right sided failure, hypotension, and higher mortality, and also with particular sensitivity to the hypotensive effects of nitroglycerine because the ischemic RV needs higher filling pressures.  Fluids are often necessary to maintain BP.  The best leads for diagnosis are leads V3R and V4R, with an ST elevation cutoff of 0.5 mm at the J-point, except for males under age 30, for whom a cutoff of 1 mm is more accurate.  As always, ST elevation should be interpreted in the context of the QRS amplitude: if QRS amplitude is particlarly high, then more ST elevation is requirred; if particularly low, then less STE is required.

Interestingly, this patient had a BP of 190/120 and required IV and oral metoprolol, as well as nitroglycerine, to control his BP.

Initial troponin I was 3.8 ng/mL.

The patient went to the cath lab and had a proximal RCA occlusion that was opened.  

Highest troponin I was 16 ng/mL

The next day, he had a formal echo.  In order to get good visualization of the RV, Intravenous Definity (brand name echo contrast material) was required.  Here is the cardiac ultrasound:

The orange colored area is the Definity contrast in the chambers of the heart.  The RV is on the left (circled below).  This shows very poor RV function except at the apex (arrow below)

Here is the formal echo report, which is remarkable for no left ventricular wall motion abnormality (all resolved!)
The estimated left ventricular ejection fraction is 69 %
The estimated pulmonary artery systolic pressure is 20 mmHg + RA pressure.
Based on the appearance of the IVC, the RA pressure is low.
Normal estimated left ventricular ejection fraction  and Normal left ventricular size.
No wall motion abnormality of the Left ventricle

Decreased right ventricular systolic performance severe .
Regional wall motion abnormality-right ventricle .


In inferior STEMI, V1 should be scrutinized for any ST elevation and RVMI should be highly suspected if there is STE, especially if there is posterior injury.  It is recommended to record a right sided ECG, as leads V3R and V4R have the best sensitivity and specificity for RV MI.  

Uncertainty Regarding and Clinical Eye

Hello friends, today is Saturday!

I bring an opinion article in IntraMed: medical news.

Here's the summary:

' Very far from what is usually believed, medical diagnosis is not the automatic application of scientific knowledge to people. Medicine is not a science, it is a human discipline based on the link and mediated communication.

A clinic is not an experimental laboratory isolated from the world.

We don´t manage diseases, we manage sick people. Pathologies are under the most diverse forms. Sculpted by the experience, the personal story, expressive, linguistic and cultural skills of an individual. It's biography as much as biology.

There is no way to turn this meeting into the reproduction of algorithms and preset courses of action without depriving it of its own foundation. Words, gestures and observation are the technologies of greater complexity that physicians have to formulate a diagnostic hypothesis. It is naive, and often dangerous, assume that the relationship built between doctor and patient can be replaced by the more sophisticated examinations.

That which some call 'clinical eye' is the product of the interpretation of the meaning of those studies that a qualified person makes subordinating them to the individual history of a patient.

The rest is secondary, often dispensable or redundant.

Authentic clinical talent consists of selection which is the infinite of possibilities with a doctor has today to study one patient rather than the mere reading of their results.

Technology gave the medicine never before imagined powerful tools. But none of them the attentive listening of a narration may be replaced or the enormous power that resides in the word to understand, accompany and heal.

No one supports the uncertainty regarding their own destiny or that of their beings dear. But medicine does not do miracles. We can not promise what we know that we can not give. The horror of' uncertainty' is an understandable response to pain or death. But the clinical diagnosis is just a probability. A mixture of science and art that brings the story of a person with the best knowledge available.

Only the formation of professionals educated in critical thinking, healthy skepticism and strong awareness of the fundamentals and the limits of their task can prevent us from that debacle.

How many patients claims for an MRI for suffer back pain, while all evidence-based guidelines recommend not to do it except in very specific circumstances?

How many parents would claim to be prescribed antibiotics to children with fever when warnings around the world are endless so that such a thing is not done?

The dramatic bacterial multidrug resistance of our days is one of its serious consequences. The absurd belief in diagnostic imaging studies to surpass and replace medical reasoning was established as part of the common sense.'.

Very interesting, what do you think?

Happy weekend

Posted in Uncategorized |

This is the doctor´s face after a 24 hour shift

Hi everybody, my dear friends.

It just sent me this new published today on ABC Dr. Cándido Pardo Rey, of the Hospital Clínico Universitario San Carlos in Madrid.

It is exposed in Granada the photographic exhibition 'Limits', showing photos of Leticia Ruiz, a young resident doctor and photographer who has captured her companions of the Hospital San Cecilio de Granada.

Their faces before and after a 24-hour shift

From enthusiasm to exhaustion. Glitter in the eyes to dark circles.

Excellent exhibition, which aims to teach the most human part of the doctors and which also aims to reclaim a job that very few times is appreciated.

Congratulations Leticia!
Click here to see the full story and video of the exhibition.

Happy Friday,



Posted in Uncategorized |

Mental Mastery in Medicine



You are the crème de la crème.

You are élite human beings. You have completed one of the most sought after and toughest apprenticeships in the world.


You have mastered multiple fine and gross motor skills, you are adept at managing multiple patients, you are able to translate from English to Medical and back again, many of you are able to do this in several other languages as well. You can reassure, trouble shoot, talk down and mediate in some of the most stressful moments of people’s lives. You have acquired a vast body of medical knowledge.

And you will continue to develop all of these skills for the rest of your careers.

You belong to an amazing, rapidly evolving, international, altruistic, knowledge sharing profession that work seamlessly with multiple other highly skilled professions.

And on this background we are now going to start developing another group of skills which has been touched on here and there in your training, but not to any significant depth. We are going to work with you to develop your mental mastery. Mastery of your greatest asset – your mind, and mastery of your patients and colleagues’ minds.

In various posts we will look at metacognition: the way we think about our thinking, positive psychology – the study of a well functioning mind (instead of psychopathology) and what is called mindfulness – the higher awareness that occurs beyond or without thinking (being mindful, similar to careful, not have a full mind).

These are areas that are in their infancy in medicine, but are rapidly growing and will transform the way we do medicine before the end of my career.

For the last few years I’ve been promoting mindfulness as a stress management tool, and a way to better listen to our patients. But in the last few years we have learned a lot, largely from military and business psychology. In the last couple of years some of the international emergency and critical care medicine gurus have been saying that meditation and mindfulness are essential skills to help us be good doctors. If we can be cool, calm and connected during a resuscitation, it is much more likely we are going to make good assessments and decisions and communicate these well with our teams.

Here’s a useful analogy. I’m testing a “Virtual Desktop” for IT. The Virtual Desktop is a new computer system that should speed a lot of our computing up. The get me to test it because it has to be fool proof. Most of the time it was working brilliantly, some times it would grind almost to a halt. As I typed there would be a time lag before anything appeared on the screen. The boffins had a look and found that there was one little programme using 99% of the computing time of the server. It turned out it was Adobe Reader. Sometime in the past Adobe had asked if it Reader could report back to Adobe how I was using Reader. Being a good eCitizen I ticked the “yes” box. It turned out that anytime I opened a PDF Reader starting reporting to Adobe non-stop “Oh, he’s rotated that ECG, and now he’s copied that, and now he’s enlarged the image, and now he’s doing nothing” etc, non-stop using 99% of the server’s brain power. The boffins disabled that programme and Virtual Desktop was fast again.

Our minds are very like this. A kid comes in with a febrile seizure.


We think “shit, it’s a kid, will I be able to get a line in” “Oh god, Cresswell’s on, he’s useless as tits on a bull, I wish we had good seniors here” “I can never find decent paeds IV lines in this department” “Oh no not that nurse, she drives me nuts” “Oh no, I’m crap at paeds” “This is going to be time consuming – what time does the café close?” “What’s the dose of midazolam for a kid” “Look at that mother’s teeth, she obviously doesn’t look after herself, she’s probably neglected this kid too” “Oh, what model iPhone has she got? Nice case” “Shit it’s a kid, will I be able to get a line in” “Oh god, it’s Cresswell on ….

And that stuff uses up 99% of our brain power. And then we only have 1% left to work on the medical stuff “Should I move him to resus?” “Should I suction him first or get the midazolam in” “Oxygen by mask or nasal prongs” …. and that 1% of brain that we have left free can’t make a friggen decision. And we see that. We see doctors freeze, we see them rock backwards and forwards between the IV gear and the suction. I’ve done 2 laps of a bed without doing anything useful because I didn’t know where to start.

A lot of the time in medicine we are suffering from information overload. There are a lot of patients, a lot of bosses, a lot of nurses, lots of relatives, lab results, X-Rays, medication lists, obs … a lot of data. And then we have to fit in our real lives: socialising, keeping our partners happy, sports, exploring NZ etc.

We also believe we should be able to multitask. We can focus on multiple patients, multiple jobs and keep all those balls in the air. Multitasking is a myth. We can only focus on one thing at a time. When we focus on many things we sequentially focus on one at a time. If we focus two things our ability to do deal with each of those things diminishes. With each thing added to our attention our performance decreases more.

Our brains are easily overloaded. We have endless questions calling for an answer. Our brains behave like a 2-year-old, throwing tantrums when it doesn’t get it’s own way or enough attention.


We are going to help you get rid of some of that mental crap.

“The empty space within a cup is what makes a cup useful”

Lao Tsu

We need to create some empty mental space within you to give you space to see the child, to think clearly, to see the parents, to see your staff, to see the big picture, to say to the health care assistant “this case is going to take a while, can you ring up the café and get them to send me a meal” and then focus back in the room again, to have space to be able to say a few words to the parents to reassure them, to have the space and humility to ask for help when you need it.

For most of us the best way to deal with a 2-year-old throwing a tantrum is not to yell “Will you shut up!”, rather it is to turn our attention to something else and wait for the 2-year-old to calm down and then give it a big hug when it has settled. Brains are similar.   We and ignore the mental chatter and focus instead on what we need to be focusing on – the patient in front of us and how our team can best help them.

A very simple, very real, exercise you can do this afternoon is to listen to a patient for one minute. Go and see a patient and ask them how they are and listen for 1 minute. Don’t try and problem solve for them, don’t try to diagnose, just listen. Just listen. If another thought pops up, just notice that, don’t try to suppress it (don’t yell at the 2-year-old), and turn your attention back to your patient.

If a nurse is telling you about a patient, stop what you are doing and just listen to what the nurse has to say, without trying to problem solve, without thinking about what else you are meant to be doing. Now after a minute if the patient is telling you about Tiddles last trip to the vet you can then disengage. If the nurse has given her or his handover, you can consider the matter and give a full attention reply.

If you do this, most of you will be surprised at how hard it is to stay focused on that one person in front of you. You may notice that you miss big chunks of that persons story. And for many of us this is how you get diagnoses very wrong, we go into a room after seeing a STEMI on the ECG and don’t hear the actual story that the patient tells us that doesn’t actually sound like cardiac chest pain and thrombolyse the STEMI mimic.

To start with the effort of focusing on the person may get in the way of actually listening, but that will quickly pass.

You may start noticing the same thing in other parts of your life. You may find that you only half listen to your partner most of the time. But that is another story.

With practice the distractions will become less intrusive. The commentaries will become less noticeable. You will find that you have 90% of your brain power available to make the key medical decisions, and you will make them quickly and move on to the next question. You act more quickly and decisively. And you will make less mistakes. And you will communicate better with your patients, their families and with your workmate.

Most of us find we need to do some special time outside of work to help us keep our mental cup empty. For some of you that may be your music, for some it will be your religious practice, for some it will be exercise, for some it will be walking on a beach.

I strongly recommend to all of you that you also do some specific training to help you be able to focus your mind on one thing at a time, one thing of your choosing. This type of mental training is commonly known as meditation, but is seen in probably all cultures in various forms: chanting, prayer and other contemplative practices.

Please try a simple meditation with me now, just for a few minutes

Please focus on your breathing. I want you to close your eyes and just focus your attention on your belly and feel the changes in sensation as you breath in and out quietly and naturally in your own time. And just gently keep your attention on your belly. If a pager goes off, unless it is an arrest pager, just notice it and turn your attention back to your belly. If any thoughts come along just notice these and return your attention back to your abdomen. etc …

If nothing else, this sort of exercise helps most people see that there is a lack of space in their awareness. For many people meditation helps to create some space in our minds.

Meditation can be particularly good to help us switch off at sleep time. When it is time to go to sleep focus on one thing. It might be your breathing, it might be the sensations in your body, starting at your feet and moving up your body, it might be listening to the sounds around you. And if any thoughts come along, work, disagreements, plans for the weekend, anything, just notice them, let them be, don’t try to suppress them, and turn your attention back to your chosen focus. Until … you wake up. If after 10 minutes the exercise is driving you nuts, stop it and go back to what ever you normally do at sleep time, but try it again the next night.

With these simple exercises: listening to one person, spending 5 minutes a day observing your breathing, and observing one thing as you go to sleep, and with much practice, you will transform yourselves from good doctors to medical masters who walk into a resus bay with an empty mind and mindful awareness and create calm. “Ah, Dr Bhatra is hear, everything will be OK”


If you can be present with that patient, not flitting off into fears or worries, if you can be present in the present, not fearful for the future, angry about the past, if you can be present in that space, and be spacious enough to hold all that is in that room, to listen, to look, to touch and really hear and see and feel, to take it all in, that will be the presence you will have.

And that will be a present, or gift or tonga [Maori word which approximately translates to "a treasure"] from you, and from your medical predecessors, to all those in the room.

This is how we will change the practice of medicine.

Enjoy your practice.



Images from


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