Case Based Discussions in Medicine 1st Edition

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Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
About the author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1: Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Case 1: Progressive dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Case 2: Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Case 3: Chest pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Case 4: Dyspnoea and confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Case 5: Back pain and breathlessness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Case 6: Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Case 7: Alcoholic liver disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Case 8: Thirst and fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Case 9: Deteriorating vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Chapter 2: Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Case 10: Abdominal pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Case 11: Bowel cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Case 12: Acute loin pain and haematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Case 13: Left iliac fossa pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Case 14: Abdominal pain and jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Case 15: Necrotic foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

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C A SE- BA SED D ISCUSSI O NS IN M ED I CINE

Case 16: Haematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Case 17: Bilious vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Case 18: Crohn’s disease: abdominal pain and vomiting . . . . . . . . . . . . . . . . 136

Chapter 3: Obstetrics, gynaecology and paediatrics . . . . . . . . . . 145

Case 19: Abdominal swelling and weight loss . . . . . . . . . . . . . . . . . . . . . . . 146
Case 20: Placenta praevia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Case 21: PV bleeding in early pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Case 22: Abdominal pain and PV bleeding . . . . . . . . . . . . . . . . . . . . . . . . . 169
Case 23: Prolonged paediatric jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Chapter 4: Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Case 24: Mania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Case 25: Post-partum psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Case 26: Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Case 27: Alcohol detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

Appendix: Figure acknowledgements . . . . . . . . . . . . . . . . . . . . 221

vi
Preface
Case-based learning (CBL) is now a thus giving a true reflection of disease
fundamental approach to teaching medical processes and how they commonly present.
students: ‘The goal of CBL is to prepare Current guidelines, scoring systems and other
students for clinical practice, through the use classification criteria are also included.
of authentic clinical cases’.
A wide range of common presentations are
This book is a study companion for medical covered. Each allows the reader to follow
students and foundation doctors. It takes the the patient’s journey. Each case covers a
reader through core clinical cases and aims to number of areas, including:
help the user become proficient at writing up
ÎÎ history-taking
a patient’s history and examination findings.
ÎÎ record-keeping
During medical school, we are told that the
patient’s history and examination is our most ÎÎ clinical findings and interpretation
valuable diagnostic tool. As students on the
ÎÎ management plan
wards, you will have sufficient time to take
comprehensive histories and examinations ÎÎ follow-up and future planning.
as they are presented in this book. Upon
Taken together, the cases will give
qualification, you will tailor your skills and the
confidence in dealing with common medical
information the patient gives you to allow a
and surgical conditions and emergencies.
more focused history and examination.
Medicine is a rapidly evolving field, so please
The cases presented will help to improve note that this book is intended to be used
clinical decision-making, clinical knowledge with current guidelines.
and patient management.
As Mahatma Gandhi said, ‘the best way to
Using real-life patient histories, each clinical find yourself is to lose yourself in the service
presentation is followed by a commentary of others.’ It is hoped that this book will guide
on the condition relating specifically to the you to medical success and help you to
presenting problem. Patients are presented gain the competencies required to become
as encountered ‘on the job’ and cases confident and knowledgeable doctors.
conclude with a discussion in terms of
Paul McNamara
anatomy, physiology and pathophysiology,

vii
About the author
Dr Paul McNamara is a registrar in emergency Paul has a keen interest in research and
medicine. He graduated with a first-class teaching. In 2017, he was awarded honorary
honours degree in Anatomy. clinical lecturer by the University of Glasgow
for his contribution to teaching. He has
He studied medicine at Glasgow University
published articles in the British Medical Journal
and qualified with a distinction and
and abstracts in the Scottish Medical Journal
commendation. In medical school, Paul
and Clinical Anatomy. He is a mentor for the
received numerous awards from the British
Reach Foundation, which encourages school
Medical Association, The Cross Trust and
students from disadvantaged backgrounds
The Trades House of Glasgow for academic
to consider tertiary education and gives them
achievement.
access to medical work experience.

viii
Abbreviations
AA Alcoholics Anonymous CBL case-based learning
AAA abdominal aortic aneurysm CBT cognitive behavioural therapy
ABCDE Airway; Breathing; Circulation; CIN cervical intraepithelial neoplasia
Disability; Exposure CNS central nervous system
ABG arterial blood gas CO cardiac output
ACE angiotensin-converting enzyme COPD chronic obstructive pulmonary
ADH antidiuretic hormone disease
AF atrial fibrillation COX cyclooxygenase
AFP alpha-fetoprotein CRP C-reactive protein
ALD alcoholic liver disease CT computed tomography
alk phos alkaline phosphatase CVA cerebrovascular accident
ALT alanine transaminase CXR chest X-ray
AMA anti-mitochondria antibody DVT deep venous thrombosis
ANA anti-cell nuclei antibody ECG electrocardiography
APER abdomino-perineal resection ECT electroconvulsive therapy
ASMA anti-smooth muscle antibody EPSE extrapyramidal side-effect
AST aspartate transaminase ERCP endoscopic retrograde
AV atrioventricular cholangiopancreatography
AVM arteriovenous malformation ERPC evacuation of retained
products of conception
AVPU alert, verbal, pain, unresponsive
ESR erythrocyte sedimentation rate
AXR abdominal X-ray
FAP familial adenomatous
BCG Bacillus Calmette–Guérin
polyposis
bd bis in die (twice daily)
FBC full blood count
BMI body mass index
FEV1 forced expiratory volume in
BP blood pressure 1 second
bpm beats per minute FIGO International Federation of
CA-125 cancer antigen 125 Gynecology and Obstetrics

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C A SE- BA SED D ISCUSSI O NS IN M ED I CINE

FVC forced vital capacity LV left ventricular

GABA gamma-aminobutyric acid LVEF left ventricular ejection fraction
gamma-GT gamma-glutamyltransferase LVF left ventricular failure
GFR glomerular filtration rate LVSD left ventricular systolic
GI gastrointestinal dysfunction
GORD gastro-oesophageal reflux mane morning
disease MCV mean corpuscular volume
GP general practitioner MDT multidisciplinary team
GTN glyceryl trinitrate MI myocardial infarction
Hb haemoglobin MRI magnetic resonance imaging
HbA1c glycated haemoglobin MS multiple sclerosis
hCG human chorionic NAFLD non-alcoholic fatty liver disease
gonadotrophin NBM nil by mouth
HDL high-density lipoprotein NG nasogastric
HDU high-dependency unit NKDA no known drug allergies
HFE hereditary haemochromatosis NMDA N-methyl-d-aspartic acid
gene
NOAC new oral anticoagulant
HLA human leukocyte antigen
nocte night
HMG CoA- 3-hydroxy-3-methyl-glutaryl-
NSAID non-steroidal anti-
reductase coenzyme A reductase
inflammatory drug
HNPCC hereditary non-polyposis
NSCLC non-small cell lung cancer
colorectal cancer
O2 sats oxygen saturation
HPV human papillomavirus
OCSP Oxfordshire Community Stroke
HR heart rate
Project
IBS irritable bowel syndrome
od omni die (once daily)
IgE immunoglobulin E
PAF platelet-activating factor
IL interleukin
PCI percutaneous coronary
INR international normalised ratio intervention
ITU intensive treatment unit PEFR peak expiratory flow rate
IV intravenous PID pelvic inflammatory disease
IVU intravenous urogram PND paroxysmal nocturnal dyspnoea
JVP jugular venous pulse PO per os (by mouth)
KUB kidney, ureters and bladder PPI proton pump inhibitor
LFT liver function test PR per rectum (rectal)
LIF left iliac fossa prn pro re nata (as needed)
LKM liver kidney microsome antibody PTH parathyroid hormone
LLETZ large loop excision of the PV per vagina (vaginal)
transformation zone
PVD peripheral vascular disease
LMP last menstrual period
RBBB right bundle branch block
LOC loss of consciousness

x
 Abbreviations

RIF right iliac fossa tds ter die sumendus

RR respiratory rate (three times daily)
RV right ventricular TFTs thyroid function tests
SAH subarachnoid haemorrhage TIA transient ischaemic attack
SaO2 arterial oxygen saturation TNF-alpha tumour necrosis factor alpha
SBR serum bilirubin level TNM tumour – nodes – metastases
SCLC small cell lung cancer TSH thyroid-stimulating hormone
SOB shortness of breath TURBT transurethral resection of
bladder tumour
SSRI selective serotonin reuptake
inhibitor U+Es urea and electrolytes
STEMI ST elevation MI UC ulcerative colitis
TACS total anterior circulation stroke UTI urinary tract infection
TB tuberculosis WCC white cell count
TCC transitional cell carcinoma

xi
Chapter 1:
Medicine
Case 1: Progressive dyspnoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Case 2: Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Case 3: Chest pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Case 4: Dyspnoea and confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Case 5: Back pain and breathlessness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Case 6: Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Case 7: Alcoholic liver disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Case 8: Thirst and fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Case 9: Deteriorating vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

1
Case 1: Progressive dyspnoea
 Presenting complaint
ÎÎ JL is an 84-year-old man who presented to hospital with a three-month history of
progressive dyspnoea and fatigue.

History of presenting complaint

ÎÎ JL first became symptomatic 1 year ago. He is a rather poor historian but remembers being
very fatigued and had noticed that his ankles had begun to swell.
ÎÎ JL also describes progressive-onset exertional dyspnoea. The shortness of breath (SOB)
had been going on for several months, but has been getting progressively more frequent
recently. In the past, it occurred with strenuous activity. Now it occurs with minimal exertion.
ÎÎ Three months ago, JL was unable to walk 50 yards without feeling breathless, and he was
having difficulty with activities of daily living such as climbing the stairs, washing and
dressing.
ÎÎ JL had an echocardiogram 3 weeks ago. On his way home, JL collapsed whilst walking and
briefly lost consciousness on his driveway. JL has a very poor memory of the events that
followed and is unaware of how he got to hospital.
ÎÎ His breathlessness was not associated with any chest pain or palpitations. He does, however,
report a persistent productive cough consisting of white sputum over the past 2–3 months,
and he has orthopnoea and occasional paroxysmal nocturnal dyspnoea.

Past medical history

ÎÎ Urticaria (2004) � Myocardial infarction (1993)
ÎÎ Duodenal ulcer � Hernia repair
ÎÎ No known history of diabetes or hypertension.

Drug history

Drug Class Dose Frequency Indication

Candesartan Angiotensin-II 4 mg od Heart failure

receptor antagonist

Bumetanide Loop diuretic 2 mg od Pulmonary oedema due to

left ventricular failure

Cetirizine Non-sedating 10 mg od Urticaria

antihistamine

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 C a se 1: Pr o g r e ssi v e dyspno e a

Drug Class Dose Frequency Indication

Omeprazole Proton pump 20 mg od Duodenal ulcer

inhibitor

Aspirin COX inhibitor 75 mg od Cardioprotection

Spironolactone Aldosterone 100 mg od Heart failure

antagonist

Bendroflumethiazide Thiazide diuretic 5 mg od Oedema

Allergies

ÎÎ No known drug allergies (NKDA).

Family history

ÎÎ Father died aged 70 from oesophageal cancer.

ÎÎ Mother died aged 76 from ‘leg ulcers and cardiac asthma’.
ÎÎ JL has a sister who also suffers from ‘swollen legs’.

Social history

ÎÎ JL has been married to his wife for 49 years; she experiences respiratory symptoms.
ÎÎ They have one son (43 years old) and one daughter (47 years old). He says both are well.
ÎÎ He has four grandchildren and two great-grandchildren.
ÎÎ JL and his wife live in a terraced house. Since the onset of oedema in his legs, he has had
significant problems with mobility. He has difficulty climbing the stairs despite handrails
being fitted.
ÎÎ JL worked as a labourer for 40 years.
ÎÎ His social support consists of his wife and children.
ÎÎ JL drank heavily in the past. When questioned further about this he was unwilling to
elaborate, simply saying that he ‘drank too much’.
ÎÎ He now seldom drinks alcohol.
ÎÎ He is an ex-smoker, having quit in 1994. He smoked 40 cigarettes/day for 40 years
(80 pack-years).

Systemic enquiry

ÎÎ Neurological: occasional headaches, poor vision, hearing aid in right ear. No dizziness, faints
or seizures. No weakness or paraesthesia.

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C A SE- BA SED D ISCUSSI O NS IN M ED I CINE

ÎÎ Cardiovascular: breathlessness at rest, orthopnoea and occasional paroxysmal nocturnal

dyspnoea (PND). No palpitations. Gross oedema of the legs to above the knee.
ÎÎ Respiratory: persistent irritating productive cough (white sputum). JL says that he is
‘exhausted’ by it. No wheeze or haemoptysis.
ÎÎ Genitourinary: nil.
ÎÎ Gastrointestinal: chronic dyspepsia. No abdominal pain. One episode of melaena 2 weeks
ago which he attributes to an episode of constipation. No overall change in bowel habit.
No nausea or vomiting.
ÎÎ Musculoskeletal: generalised muscle cramps, especially in the hands and legs. No pain or
weakness in any joint.

Physical examination

General
ÎÎ Elderly, slightly overweight man who is sitting upright and is clearly breathless. He is
cyanosed and has a pale complexion.

Vital signs
ÎÎ Temperature 36.4°C
ÎÎ Blood pressure (BP) 105/50 mmHg
ÎÎ Heart rate (HR) 60 bpm (beats per minute), regular
ÎÎ Respiratory rate (RR) 22 breaths/minute
ÎÎ Arterial oxygen saturation (SaO2) 95%.

Neurological
ÎÎ Patient is orientated to person, time and place
ÎÎ Motor: good bulk and tone; strength is 5/5 throughout
ÎÎ Cerebellar: finger–nose, heel–shin and rapid alternating movement responses are intact.

Cardiovascular
 Top tip
ÎÎ No visible jugular venous pulse (JVP)
How you would tell the difference
ÎÎ Unable to palpate apex beat between PVD and pedal oedema?
ÎÎ S1, S2; regular rate; no murmurs The most reliable physical findings of PVD
ÎÎ Bilateral leg oedema to level above the knee are diminished or absent pedal pulses,
presence of femoral artery bruit, abnormal
ÎÎ Unable to palpate posterior tibial and skin colour, and cool skin temperature.
dorsalis pedis pulses, probably due to JL had none of these. His main clinical sign
severity of bilateral leg oedema rather than was gross pedal oedema.
peripheral vascular disease (PVD).

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 C a se 1: Pr o g r e ssi v e dyspno e a

Respiratory
ÎÎ No use of accessory muscles
ÎÎ Tachypnoea
ÎÎ Thorax symmetrical with good expansion
ÎÎ Right lung resonant; vesicular breath sounds
ÎÎ Left basal mid-inspiratory crackles
ÎÎ Dyspnoeic at rest.

Gastrointestinal/abdominal
ÎÎ No spider naevi or signs of anaemia; no hepatic flap
ÎÎ Inguinal hernia scar
ÎÎ Hepatomegaly
ÎÎ Distended, non-tender abdomen.

Musculoskeletal
ÎÎ Full range of movement in all joints; no deformities.

 Red flags
ÎÎ Unprovoked exertional collapse
ÎÎ Dyspnoea at rest, orthopnoea and PND.

 Summary of patient’s problems

ÎÎ Dyspnoea at rest
ÎÎ Bilateral leg oedema to above the knee
ÎÎ Poor mobility related to dyspnoea and fatigue.

 Questions
ÎÎ Based on the patient’s symptoms, what are the main differential diagnoses?
ÎÎ What initial investigations would help confirm the diagnosis?
ÎÎ What is your immediate management plan?

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C A SE- BA SED D ISCUSSI O NS IN M ED I CINE

Differential diagnosis
History and examination make left ventricular systolic failure the most likely diagnosis. JL had
bilateral crepitations in his chest and gross pedal pitting oedema.
Consider what further investigations would rule out the other potential differential diagnoses below:
ÎÎ pneumonia (productive purulent sputum, fever, consolidation on chest X-ray [CXR])
ÎÎ bronchiectasis (chronic condition, does not normally present acutely – productive cough,
frequent exacerbations, stereotypical computed tomography [CT] findings)
ÎÎ fibrosis (dyspnoea, usually no peripheral oedema, or PND)
ÎÎ asthma/chronic obstructive pulmonary disease (COPD) (possible but again not normally
associated with pedal oedema)
ÎÎ lung cancer (usually a history of chest discomfort, weight loss, haemoptysis)
ÎÎ chronic renal failure (can cause oedema, but more unlikely given JL’s other symptoms).

Management plan
ÎÎ Oxygen (100%)
ÎÎ Gain IV access
ÎÎ Bloods – full blood count (FBC), urea and electrolytes (U+Es), C-reactive protein (CRP),
troponins, brain natriuretic peptide (BNP)
ÎÎ Electrocardiography (ECG) – look for signs of myocardial infarction (MI)
ÎÎ CXR – look for cardiomegaly, signs of pulmonary oedema: shadowing, small effusions at
costophrenic angles, fluid in the lung fissures, and Kerley B lines (linear opacities)
ÎÎ Echocardiogram – can indicate cause of heart failure and may indicate left ventricular (LV)
dysfunction
ÎÎ Morphine 5 mg IV
ÎÎ Furosemide 40–80 mg IV
ÎÎ Leg ultrasound to exclude deep venous thrombosis (DVT).

Results of investigations
Chest X-ray
Pulmonary oedema and cardiomegaly:
look for shadowing, small effusions at
costophrenic angles, fluid in the lung
fissures, and Kerley B lines (linear opacities).

Leg ultrasound
The femoral and popliteal veins compress
fully and show normal augmented flow
on calf compression, with no signs of
femoropopliteal DVT in either leg.

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 C a se 1: Pr o g r e ssi v e dyspno e a

ECG
ÎÎ Sinus rhythm
ÎÎ Right bundle branch block (RBBB).

Characteristic changes in RBBB: delayed activation of the right ventricle results in an rsR pattern
in V1 and a wide negative S wave in V6 (mnemonic MaRRoW).

Echo
Severe left ventricular systolic dysfunction (LVSD).

 Question
ÎÎ What pharmacological treatments should be considered for the long-term management
of heart failure?

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C A SE- BA SED D ISCUSSI O NS IN M ED I CINE

Diagnosis
ÎÎ Pulmonary oedema secondary to LVSD.
The combination of dyspnoea, PND and orthopnoea coupled with the examination findings
such as crepitations in JL’s chest and bilateral pedal oedema strongly suggest LVSD.
The diagnosis is made by the CXR findings of cardiomegaly and pulmonary oedema.
His echo also confirmed severe LVSD.

Further management plan

ÎÎ Daily weighing; BP and pulse/6 h
ÎÎ Repeat CXR
ÎÎ Change to oral furosemide or bumetanide
ÎÎ Angiotensin-converting enzyme (ACE) inhibitor for LVF (left ventricular failure)
ÎÎ Beta-blocker and spironolactone
ÎÎ Consider digoxin (if atrial fibrillation [AF])