We have listened to people who use ‘Good Medical
Practice’ in their work - doctors in practice, NHS
managers, patient representative groups and
others. The new edition, refined in the light of their
views, includes:
 emphasis on maintaining good medical practice
through personal, professional development, audit
and appraisal
 the duties of medical teachers
 the importance of effective team working
 the doctor’s duty to tell patients if things go
wrong, apologize where necessary, and put things
right if possible
 more emphasis on reporting dysfunctional
practice.
CASE 1
Mrs H.G.
54 years old
• Developed sudden onset of severe
headache, vomiting, neck stiffness
in September ’07
• Following day drooping of left
eyelid was noted
CASE 1
• Attended Moka Eye Hospital
• Ct scan brain done 2 days later at JNH
• Discharged and prescribed eye drops
and parentrovite injection
• Headache persisted together with
drooping eyelid
• Attended VH in October ’07
• Findings: left 3rd cranial nerve palsy
• Referred to medical unit
CASE 1
• Further CT brain requested at
JNH reported as having small
lacunar infarcts
• Patient seen by 2 specialists
(physicians) and was about to be
discharged home
• INTERVENTIONS FROM
HIGHER QUARTERS
CASE 2
Mr B.C.
44 years old
• H/o headache, irritability, confusion
and personality change since 3 months
• Recently developed urinary
incontinence
• Attended hospital
• Given symptomatic treatment
• Condition worsening and patient taken
to psychiatrist
CASE 2
• CT scan brain: huge bifrontal tumour
• Operation in May ’07
• Right-sided tumour removed and
divided into two halves
• Report 19/05/07 from private lab:
Appearance consistent with meningioma
• Report 18/06/07 from VH:
Metastatic undifferentiated carcinoma
CASE 2
• Four blocks submitted for counter
examination Durban, South Africa
• Report July ’07:
Meningoma; no abnormal mitosis, no
cytological evidence of malignancy
• Subsequent report from VH lab August
’07:
Cellular malignant neoplasm of
meningeal origin
Frequent mitoses and foci of necrosis
Nuclear polymorphism conspicuous
CASE 2
• Is it a meningioma with no mitotic
activity requiring no further
treatment?
• Is it a metastatic undifferentiated
carcinoma (to look for primary)?
Radiotherapy? Chemotherapy?
• Is it a meningioma? Aggressive,
anaplastic type, requiring
radiotherapy?
CASE 3
Mr R.Y.
43 years old
• Airline pilot, referred from Seychelles
• Medical report stating that he had a
brain tumour on CT scan
• No CT scan films sent with patient
• Presenting symptoms:
Sudden onset of headache, vomiting,
collapse and urinary incontinence one
week earlier
CASE 3
• On examination:
 Patient conscious
 Headache ++
 Neck stiffness
 Provisional diagnosis of sub- arachnoid
hemorrhage
MRI and MRA brain requestedReport: Normal study
• What next?
CASE 4
Mr I.C.
67 years old
• Collapsed in bathroom
• Unconscious; brought by SAMU to
hospital
• Admitted to Cardiac Unit with
diagnosis of CVA
• CT scan brain showed extensive subarachnoid hemorrhage
• Transferred to ICU and put on
ventilator
CASE 4
• Gradual improvement in clinical
condition, from grade IV to grade I
• Extubated and transferred to
private clinic for CT Angio
• Result:
No evidence of aneurysm or AVM
• What next?