Clinical Cases - A Step-by-Step Approach (April 12, 2021)_(0815367287)_(CRC Press) 9780815367284, 9780815367147, 9781351257725

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CUnical Cases

A Step - by - Step Approach Andrew Solomon Julia Anstey Liora Wittner With contributions from Priti Dutta

CRC Press Taylor & Francis Group

Clinical Cases

Clinical Cases A Step-by-Step Approach Andrew Solomon, BM BCH MA(Hons) DM FRCP Consultant Physician East and North Hertfordshire NHS Trust Stevenage, UK Julia Anstey, BSc (Hons) MBBS Foundation Doctor Somerset NHS Foundation Trust Taunton, UK Liora Wittner, MBBS BSc Resident in Internal Medicine Shamir Medical Centre Be’er Ya’akov, Israel With contributions from Priti Dutta, MBBS BSc FRCR Consultant Radiologist Royal Free London NHS Foundation Trust London, UK

First edition published 2021 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN © 2021 Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, LLC This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not available on CCC please contact [email protected] Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. ISBN: 978-0-8153-6728-4 (hbk) ISBN: 978-0-8153-6714-7 (pbk) ISBN: 978-1-351-25772-5 (ebk) DOI: 10.1201/9781351257725 Typeset in Minion Pro by Deanta Global Publishing Services, Chennai, India

Contents

Foreword by Jeremy Turner

vii

Foreword by Claire Macaulay

ix

Preface xi Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Case 11 Case 12 Case 13 Case 14 Case 15 Case 16 Case 17 Case 18 Case 19 Case 20 Case 21 Case 22 Case 23 Case 24 Case 25 Case 26 Case 27 Case 28 Case 29 Case 30 Case 31

1 7 11 15 19 23 27 31 37 43 47 53 59 63 71 79 85 91 95 103 107 111 115 121 125 129 139 145 155 159 165 v

vi Contents

Case 32 Case 33 Case 34 Case 35 Case 36 Case 37 Case 38 Case 39 Case 40

169 175 179 183 189 193 197 201 207

List of Abbreviations

215

Index 221

Foreword

When Aneurin Bevan set up the NHS in 1948, medicine was dominated by relatively acute illness. Pneumonia, industrial accidents, childhood infections and the like were the order of the day. This cultural legacy lasted well into the modern era with many textbooks and much medical education still focusing disproportionately on the acute illness. Much of my own post-graduate pedagogic experience was dominated by clinical case books teasing the learner with the differential diagnosis of acute hepatitis, lengthy lists of rare causes of pericarditis, photosensitive rashes and orogenital ulceration. The plain truth of the matter is that the majority of the time, medicine isn’t really like this any longer. We have long since transitioned to the era of the long-term condition, the chronic illness and the poly-comorbid patient. Patients and their diseases frequently coexist, side by side, for decades, the one influencing the course of the other and vice versa.

With this enlightening, educational, insightful and sensitively written series of cases, the clinical case book is brought into the modern era. The authors have pulled off a masterful job of interweaving contemporary medical education, updating the reader on the latest guidance and thinking, with a sensitive and at times touching investigation of the effect of patients’ diseases on their life course and vice versa. Students, graduates preparing for specialist exams and others will enjoy and benefit from this lovely book. Professor Jeremy Turner, MBBS BSc FRCP DPhil (Oxon) Consultant Endocrinologist Department of Diabetes & Endocrinology NNUH Honorary Professor Norwich Medical School Clinical Director NIHR CRN: Eastern Research Network

vii

Foreword

A consultation is a meeting of two experts: the doctor who is an expert in medicine and the person accessing care who is an expert in how their condition affects them and their life. As the National Education Lead for Realistic Medicine at NHS Education for Scotland, I am passionate in supporting newly and nearly qualified doctors to adopt a person-centred approach to their work, which may sometimes look and feel quite different from the style of their more senior colleagues. People with a serious or chronic health condition live with the implications of it every day. As a doctor, your interactions form only a tiny part of the lived experience of the people who seek your help. I would suggest that for your medical advice and intervention to have any impact, you need to know what matters to the person who will live with the consequences. Shared decisionmaking, where people are fully involved in the healthcare decisions that affect their lives, should be the standard consultation style in 21st-century medicine. This book provides a novel approach to understanding the trajectory of disease processes over time. But more than that, this book demonstrates how the wishes and goals of the person at the centre shape the decisions made and the outcomes.

Take the case of Mrs Deane, the 76-year-old woman who is diagnosed with metastatic breast cancer. A different person may have chosen to try chemotherapy, but Mrs Deane is clear that this is not the route for her. This is a reasonable decision; just because we can do something does not mean that we should. As a doctor, it is important to share the option of doing nothing as a legitimate treatment. In Mrs Deane’s case, her main concern is hip pain, and shared decision-making with her consultant leads to a personalised approach which fulfils her specific needs. The authors of this book have created a compendium of real-world cases that will challenge your medical acumen but will also challenge you to consider how you make decisions and the implications of those decisions for the lives of the people you are trying to help. Put yourself in the shoes of the fictional characters portrayed here – would you make the same choices as them? Each person that you interact with in your career will have their own values, needs and backstory. Your job is to encourage them to share these and listen to them when they do. Dr Claire Macaulay, MD MRCP MBChB (Hons) BSc (Hons) National Education Lead for Realistic Medicine NHS Education for Scotland

ix

Preface

Clinical medicine involves the intertwining of the lives of our patients with the health conditions that affect them. The course of an illness may change in a matter of seconds or hours, but many conditions progress and impact on the life of the patient for several months or even years. With an increasing reliance on shift work, handovers and specialist referrals, seeing patients longitudinally throughout their illness is less common than it used to be. This has had a significant effect on our education and understanding of disease progression. In the past, clinical case books have all too often provided a snapshot in time, looking at what happens to patients during a single episode. A short vignette leads directly to questions focused on identifying the diagnosis and the immediate treatment required. However, we feel that this ignores the way in which the process of disease affects both our patients and our care for them. We feel the need for a new paradigm that looks at a longer time period, acknowledging the existence of developing clinical presentations and complications which may present over the course of several chronological episodes. Therefore, we have developed a new style of clinical cases, presenting the cases with a timepoint structure, taking you step-by-step through key moments where new information becomes available, where investigations require action, or other moments where there is an important learning point. We have created a series of clinical cases which cover a range of important medical conditions, constituting around five cases for each of the major internal medical specialities: cardiology, respiratory, gastroenterology, endocrinology,

rheumatology and neurology. Other important areas such as oncology, infectious disease, toxicology, haematology, renal medicine and geriatrics are also covered to make up a total of 40 cases. This book is designed to complement the learning of senior medical students and doctors early in their training. The scope includes scenarios based within hospital medicine but, importantly, also includes timepoints based in primary care and other community settings, as these are also places where junior doctors are expected to practice semi-autonomously. We are deeply grateful for the help and support provided by a wide range of people in the development of this book. First and foremost, we would like to thank Dr Priti Dutta, a remarkable radiologist, who has contributed all of the outstanding radiology images included in this book. We thank those who have contributed partial clinical cases: Dr Tara Belcher, Dr Sophie Anne Elands, Dr Martin Glasser and Dr Rachel Tresman. We are also grateful to a number of people who have reviewed and edited content, including Dr Rebecca Bamford, Dr Katya Christodoulou, Dr Asma Fikree, Dr David Fisher, Louise Greenberg, Dr Catriona Hayes, Dr Rammya Mathew and Dr Yael Santhouse. Finally, we would like to thank our exceptional publishing team at CRC Press, Jo Koster and Julia Molloy, without whom this book would not have been possible. Please inform us of any errors or anything else that you feel is worthy of comment for future editions. Enjoy! From the co-author team, Andrew Solomon, Julia Anstey and Liora Wittner xi

Case 1 TIMEPOINT  1 Mr Marsh, a 35-year-old teacher, has presented to the emergency department with a 2-day history of feeling weak in his legs and increasing difficulty walking. He is normally very active and plays football in his spare time; however, he is now finding it difficult to stand for more than a few minutes. Over the last day, he has started to suffer from pins and needles in his arms and feet and has pain in the rear of his neck. His bowels are functioning normally, but he has found that he is urinating more frequently than usual. Prior to this, Mr Marsh has been generally well, apart from having ‘food poisoning’ 3 weeks ago. He has no significant past medical history, is currently on no medications and has no drug allergies. He does not smoke and drinks alcohol socially twice a week. His observations are: Respiratory rate: 14/min Oxygen saturations: 99% on room air Temperature: 36.8°C Blood pressure: 112/74 mmHg Heart rate: 72 bpm On examination, Mr Marsh looks generally well. Cardiorespiratory and abdominal examinations are normal. A neurological examination of the upper limbs revealed asymmetric and variable power in the biceps, triceps and other muscle groups with altered sensation in an indistinct distribution across both arms. Examination of the lower limbs revealed increased tone, generalised reduced power (MRC 4+) amongst all muscle groups, normal to brisk reflexes, positive Babinski sign and generally impaired coordination. Rectal exam showed normal tone.

DOI: 10.1201/9781351257725-1

What investigations should be arranged? ●● ●● ●●

●● ●● ●●

Urinalysis Bladder scan Bloods – FBC, U&Es, ESR, CRP, serum B12 and folate Lumbar puncture (preceded by CT head) MRI spinal cord MRI brain

Urinalysis was normal. A bladder scan showed an empty bladder. Initial blood tests showed the following: Venous blood results Haemoglobin White cell count Platelets Sodium Potassium Urea Creatinine

140 g/L 6.0 × 109/L 253 × 109/L 139 mmol/L 4.4 mmol/L 6.1 mmol/L 90 μmol/L

A lumbar puncture was performed, which showed the following: Lumbar puncture results CSF fluid CSF protein CSF glucose CSF cell count Plasma glucose Gram stain

Clear 1.2 g/L 4.1 mmol/L High 4.8 mmol/L No organisms

1

2  Clinical Cases

The MRI spine is shown in Figure 1.1.

The clinical findings suggest a diagnosis of idiopathic transverse myelitis.

What are the diagnostic criteria for transverse myelitis? The Transverse Myelitis Consortium Working Group suggests the following diagnostic criteria: ●●

●●

●● ●●

●●

●●

Figure 1.1  (a) Sagittal T2 MRI image through the cervical spine; (b) Sagittal T1 images through the cervical spine; (c) The red line demarcates a long segment of abnormal T2 increased signal within the cord. Imaging diagnostic criteria for transverse myelitis involve the demonstration of long segments (3 to 4 vertebral body heights or more) of spinal cord signal change, occupying more than two-thirds of the cross-sectional area of the cord. These may demonstrate variable patterns of enhancement and restricted diffusion

The MRI is reported as follows: altered T2 and gadolinium enhanced signal within the spinal cord from the level of C3 to C7, with no suggestion of any compressive/space-occupying lesion.

Development of sensory, motor or autonomic dysfunction attributable to the spinal cord Bilateral signs and/or symptoms (though not necessarily symmetric) Clearly defined sensory level Exclusion of extra-axial compressive aetiology by neuroimaging (MRI or CT myelography) Inflammation of the spinal cord demonstrated by CSF pleocytosis, elevated IgG index or MRI gadolinium enhancement Progression to nadir between 4 hours and 21 days following the onset of symptoms

A significant percentage of patients presenting with a clinical pattern resembling transverse myelitis do not meet the inflammatory features of the criteria. It is important to note that the absence of inflammatory markers does not exclude transverse myelitis as the diagnosis.

How should Mr Marsh be managed? First line: high-dose IV glucocorticoids for 3–5 days (either methylprednisolone, 1000 mg daily, or dexamethasone), alongside supportive care and acute rehabilitation. Second line: plasmapheresis with supportive care and acute rehabilitation – for CNS demyelinating diseases that fail to respond to glucocorticoids.

TIMEPOINT  2 Four days after admission, Mr Marsh is seen on the morning ward round. He says he is starting to

Case 1: Timepoint 4 3

feel better already, and has been working with the physiotherapists to try to get his strength back. He has been having regular bedside capillary blood glucose monitoring after starting on steroids. The nurse notes that he had one value of 9.8 mmol/L yesterday evening, but all of the values preceding this had been