Monday, 21 March 2011

Clinical queries

A (public) collection of clinical queries for my own CME. Please feel free to comment!

In patients with ischaemic stroke and essential thrombocythaemia some papers suggested referring to haematology.[1] Which patients with stroke and apparent essential thrombocythaemia should be referred?*

Almost all patients on the medical admissions unit round had a C-reactive protein result in the notes. Admittedly I am seeing the 'complex discharge patients' so the diagnoses may not be so straight forward in them but still seemed a high figure to me and unnecessary CRPs are well known in the literature.[2] Which patients require CRP on acute admission? Is there a local policy?

1. Richard S, Perrin J, Baillot P, Lacour J, Ducrocq X. Ischaemic stroke and essential thrombocythemia: a series of 14 cases. Eur. J. Neurol. 2010. Available at: [Accessed March 21, 2011].

2. Kelly AP, Murphy AM, Hughes R. A retrospective analysis of the use of C-reactive protein assays in the management of acute medical admissions. N. Z. Med. J. 2009;122(1293):3559. Available at: [Accessed March 21, 2011].

* I've edited this entry following a discussion on #nhssm [March 23rd 2011]. It was based on a patient I had seen recently (as most clinical queries would be). The emphasis is now on my particular learning point and not any details of the case.


  1. I can't access the paper on thromobocythaemia. Since aspirin is the treatment in this range why would you need to refer to a haematologist? What would they do?

    Next, CRP is probably over-ordered in primary care as well although the indications are pretty vague here:

    You would know better than me whether there is a local policy:)

  2. Oh I do have access! The paper doesn't tell me a lot more except that referral should be made so that diagnosis could be confirmed- do you think that is necessary?

  3. In this case I was the one who made the diagnosis of the probable essential thrombocythaemia. It looked pretty much like it to me but there were some other minor abnormalities too and there was nothing documented on the FBC report. In my last hospital they would usually have picked it up and put something in the report. I'm just highlighting my uncertainty.

    I'm not sure if there is a local policy on CRP. I've only just started in the Trust so it should be something I can investigate.

    Wonder if this public honesty about my learning is really worth it?

  4. that's what we all wonder:) I do like Tilt though ... think there is lots of potential