Alliteration

Medical students use alliteration and a lot of mnemonics to help learn anatomical relationships, causes of various clinical signs and symptoms and the signs and symptoms of various diseases. They also string together letters, words and even sentences and use alliteration to better their cause. One example of alliteration, used to describe the classical person who presents with disease of the gall bladder and/or biliary tract, is Fair, Fat, Fertile, Female of Forty – the five Fs.

Enterprising medical students will make up their own mnemonics or supplement some that already exist. The Five Fs, for instance, can easily become the ten Fs in a fertile young mind – Fair, Fat, Fertile, Flatulent, Fecund, Fervent, Febrile, Female of Forty or Fifty.

At about nine am the nurses asked me to see a thirteen-year-old girl who had severe abdominal pain and vomiting. I took one look at the mother, sitting, worried, alongside the bed and the five Fs sprang immediately to mind. The girl, too, was very big for her age - both tall and very much overweight. I thought to myself that she would doubtless follow in mother’s footsteps and also become a Five F later in life.

Anyway, I was able to determine that the pain had started about four hours earlier in the wee small hours; that it was colicky in nature – that is, it was present continuously but also came in waves of much greater severity. It was present in the upper abdomen in the midline but also radiated into her chest and through to her back between the shoulder blades. She had a strongly positive Murphy’s sign when I examined her abdomen. That means that when I pressed as firmly, deeply and as gently as possible over the right upper abdomen and asked her to take a deep breath in, she felt a severe stabbing pain and stopped inhaling. I did that once only. I could find no other abnormality.

This threw me into a bit of a quandary. The history I had obtained from patient and mother and the findings on examination led me to a diagnosis of biliary colic. This means she had a stone in her gall bladder or in the duct leading from the gall bladder down through the pancreas into the intestines and, probably, an inflamed gall bladder. The quandary was that I had never heard of such a condition in a thirteen year old. I had to be wrong. There had to be an alternative diagnosis - but I could not think of one.

Anyway, the history and examination had taken less than five minutes and the poor girl desperately needed relief from her pain. We inserted a cannula into a vein in her arm and took blood for a battery of tests. We gave intravenous morphine to ease the pain and metoclopramide to stop the vomiting. We then put up a drip of saline solution to replace the fluids she had lost through vomiting. It was fortunate that she had good, accessible veins in her arms. Obesity usually causes the veins to disappear under a layer of fat and become very difficult to cannulate. While all this was going on I explained my diagnosis to Mum and patient and also confided that I had never seen anyone so young with that diagnosis. I wrote up my notes, filled in the laboratory request form and also wrote a form requesting an ultrasound examination of the gall bladder.

I discussed my patient with another doctor. She felt my diagnosis was highly unlikely but could not offer an alternative. She agreed I had to at least exclude biliary colic before proceeding to further investigations.

An hour later the blood reports arrived - all entirely normal. That was reassuring and excluded a heap of other diagnoses. Meanwhile the patient’s pain had resolved completely. The morphine had worked, of course, but now she had no pain at all. That fitted my diagnosis because the classic pain of biliary colic lasts about four to six hours – the time usually taken for a gall stone to pass from the gall bladder into the intestine. It causes pain by stretching the ducts and causing them to go into extremely painful spasm. The stones are too small to dilate the intestine therefore, when they reach there, the pain stops.

Then the orderly took her away for the ultrasound examination. She returned beaming and happy; as was her mother. The technician had shown them other gall stones in the gall bladder and had found nothing in the ducts. They both thought the sun shone out of me. I was amazed and a bit non-plussed. I decided to wander down to the x-ray department and have a chat with a radiologist about it all. He was laid back and not a bit surprised that a thirteen-year-old had gall stones. “Not common, mind you, at thirteen, but we see lots of them in women of eighteen or twenty.”

I gave Mum a copy of the ultrasound report and advised them to take it to their GP. The girl would need to see a surgeon and have her gall bladder removed. Until that is done she is at high risk of another attack of colic and also of infection in the gall bladder not to mention a stone causing obstruction to the ducts. These latter two conditions are life threatening.

Perhaps the mnemonic should now read – Fair, Fat, Fertile, Females of Firteen.

I suppose the good news part is that most gall bladder surgery these days is done by laparoscopic “keyhole” surgery. I had mine removed this way a few years ago. It wasn’t a lot of fun but far less painful than the old-fashioned slash across the belly with its associated high rate of complications. I only scored two of the Fs – Fat, (well, let’s just say a little overweight), and Fertile, (I’ve fathered two offspring). I’m by no means Fair, I’m not Female and I was sixty five when I had the surgery – not Forty, Fifty - or Firteen.

The afore-mentioned Murphy, by the way, is not the one whose Law dictates that if anything can possibly go wrong then it will. Ours is John Benjamin Murphy (1857-1916) – the “stormy petrel” of American surgery early in the twentieth century. He was an innovative and flamboyant surgical genius and tall poppy and challenged many surgical principles of the time. Some of his contemporaries tried, unsuccessfully, to cut him down. He was called to attend President Theodore Roosevelt after he was shot in the chest but elected to treat him conservatively and leave the bullet in place. Roosevelt survived. Murphy described several other different tests and observations used in medical examinations and diagnoses.

On the subject of mnemonics, medical students all over the world use them to memorise the names of the twelve pairs of cranial nerves. “On Old Olympus Towering Top A Finn And German Viewed Some Hops” was one I used. The first letter of each word is the first letter of the name of a cranial nerve. E.g. “O” = Olfactory; “V” equals Vagus and so on. I have never forgotten the mnemonic but now struggle to remember the names of the relevant nerves. Wikipedia lists no less than forty different mnemonics for the cranial nerves. Many attest less to the inventive minds of students than to their prurience.

Abbreviations save us a lot of writing. FOOSH means Fell Onto Out Stretched Hand. NOF means Neck Of Femur and usually that it is a fracture of that bone. AAA does not mean First Class or 1.5 volts but Abdominal Aortic Aneurism – usually leaking or ruptured. BIBA – Brought In By Ambulance. SOAP – Subjective, Objective, Appraisal, Plan – a logical method of writing up medical notes. Some doctors actually use the letter, or even the word, as headings for the sections. NAD – No Abnormality Detected. But it is a brave young doctor who will use this abbreviation if working for a pedantic boss. For instance, if the notes contain the words, “Cranial Nerves NAD’ and the boss finds an abnormality when examining that patients cranial nerves he/she might say, “By this I presume you means that examination of the cranial nerves was Not Actually Done?” Should this eventuate then the BYD (Brave Young Doctor) can expect it to be said in public, (on a ward round for instance), and in a tone of voice dripping sarcasm and scorn.

PU – pass/ed urine. IDUC – Indwelling Urinary Catheter. TURP – Trans Urethral Radical Prostatectomy. A note might say, “TURP 5/7, RO IDUC, PU.” A more succinct way of saying – “This patient had a Trans Urethral Radical Prostatectomy five days ago. The Indwelling Urinary Catheter was removed and he subsequently passed urine.”

There are, literally, hundreds of other abbreviations used in medicine. Taken out of the context of medical notes, journals or books most are meaningless. Very few ever become part of everyday language but one outstanding exception is CABAG – Coronary Artery Bypass Graft. This method of surgically treating blockages in the arteries supplying the heart muscle has become so common place that the mnemonic has become an English language neologism. When we are taking a medical history from a patient, and enquire about previous operations, patients will often volunteer, “Had me cabbages done a couple of years ago.”