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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
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
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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
is 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. e 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. e 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. e 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. is book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medica l professional to make his or her own professiona l judgements, so as to advise and treat patients appropriately. e authors and publishers have also attempted to trace t he copyright holders of all material reproduced in this publication and apolog ize 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 a s permitted u nder U.S. Copyr ight Law, no part of th is book may be repri nted, reproduced , transmitted, or uti lized in a ny form by any electronic, mechanical, or other means, now known or hereaer 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 mpkbookspermissions@tandf.co.uk
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
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Foreword by Jeremy Turner vii
Foreword by Claire Macaulay ix
Preface xi
Case 1 1 Case 2 7 Case 3
11 15
Case 4 Case 5
19
Case 6
23 27
Case 7 Case 8
31 Case 9 37 Case 10 Case 11 Case 12 Case 13 Case 14 Case 15 Case 16 79 Case 17 Case 18 91 Case 19 Case 20 103 Case 21 107 Case 22 111 Case 23 115 Case 24 Case 25 125 Case 26 129 Case 27 139 Case 28 145 Case 29 155 Case 30 159 Case 31 165
43 47 53 59 63 71
85
95
121
v
vi Contents
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Case 32 169 Case 33 Case 34 Case 35 Case 36 Case 37 193 Case 38 Case 39 Case 40
175 179 183 189
197 201 207
List of Abbreviations
Index 221
215
Foreword
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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. is 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. e 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. e 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
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Foreword
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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.
is 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. is 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.
e 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