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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
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
https://t.me/medicina_free
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 hereaer 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
https://t.me/medicina_free
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 BScFRCPDPhil (Oxon)
Consultant Endocrinologist
Departmentof Diabetes & Endocrinology
NNUH
Honorary Professor
Norwich Medical School
Clinical Director
NIHR CRN: EasternResearch Network
vii

https://t.me/medicina_free

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
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