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88 Clinical Cases
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Key points
Preparation
Find a quiet and private location
Avoid giving bad news over the
phone if possible
Consider whether the patient may
want a friend or family member
present
Turn off bleeps and mobile phones
Consider booking a double appointment if in a clinic setting
Ensure that you have read through
the notes and are familiar with all of
the facts
Communication
Establish what patient already
knows
Avoid jargon and abbreviations
Pause to check understanding
Give a warning shot before breaking
the news
Consider how much detail the
patient may or may not wish to
know – follow patient cues
Reassure without providing false
hope
Closing
Explain next steps
Arrange appropriate follow-up, e.g.
with specialist nurses
Give written material if possible
Given the presence of bone metastases, the consultant asks the junior doctor to add on a calcium
level to the morning bloods.
Malignancy
Related to malignancy directly
– Ectopic PTH, calcitriol or parathyroid
hormone-related peptide production
Related to bone metastasis
– Uncommon but can occur with
mesothelioma
– More common tumours to metasta-
sise to bone include lung, breast, renal
and myeloma
Medication-induced, e.g. thiazide diuretics,
lithium
Rhabdomyolysis
yrotoxicosis
Phaeochromocytoma
Primary adrenal insufficiency
Sarcoidosis
Tuberculosis
Tertiary hyperparathyroidism
Approximately 90% of cases of hypercalcaemia
are due to either primary hyperparathyroidism
or malignancy.
What are the symptoms of
hypercalcaemia?
Nausea and vomiting
Polyuria
Low mood and confusion
Weakness
Abdominal pain
Arrhythmias (shortened QTc)
Drowsiness
Constipation
How should hypercalcaemia be
managed?
TIMEPOINT 3
Later that day, the junior doctor on the ward is
chasing up Mrs North’s blood test results. Her
calcium comes back as 3.4 mmol/L.
What are the causes of
hypercalcaemia?
Primary hyperparathyroidism
Check renal function, liver function, thyroid
function, myeloma screen, phosphate levels
and parathyroid hormone levels to look for
an underlying cause. Assess fluid balance and
perform an ECG
Rehydration with 0.9% sodium chloride
Give 4–6 litres over 24 hours
Consider giving loop diuretics if fluid
overload (monitor elderly patients or
Case 17: Timepoint 4 89
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Table 17.1 Examples of anticipatory medications and sample doses
Sample syringe driver dose
Sample subcutaneous
Symptom Medication
Pain
(opioid-naïve)
Pain
(already using
morphine)
Breathlessness Midazolam 2.5 mg 2–4 hourly 10–20 mg/24 hours
Nausea Cyclizine 50 mg 8 hourly 100–150 mg/24 hours
Secretions Glycopyrronium
Anxiety and
agitation
Delirium and
agitation
Morphine
sulphate
Morphine
sulphate
bromide
Midazolam 2.5–5 mg 2 hourly 10–20 mg/24 hours
Haloperidol 1.5–3 mg 2 hourly 1.5–10 mg/24 hours
2.5–5 mg 2–4 hourly 10–20 mg/24 hours
Divide total daily oral
e.g. current dose 30 mg
0.2 mg 6 hourly 0.6–1.2 mg/24 hours
PRN dose
morphine dose by 12
MST BD = 60 mg per day
60 ÷ 12
hourly
= 5 mg 2–4
(continuous subcutaneous
infusion/CSCI)
Divide total daily oral morphine
dose by 2
e.g. current dose 30 mg MST BD
= 60 mg per day 60 ÷ 2
mg over 24 hours
= 30
those with renal impairment carefully).
Consider need for dialysis if severe renal
impairment
●
Intravenous bisphosphonates
●
Give aer rehydration
●
Take 2–4 days to reach full eect
●
Options
– Zoledronic acid 4 mg over
15minutes
– Pamidronate 30–90 mg at
20 mg/hour
– Ibandronic acid 2–4 mg
●
Second-line treatments include prednisolone,
calcitonin and cinacalcet. Parathyroidectomy
may be required in severe acute primary
hyperparathyroidism
TIMEPOINT 4
e next day, aer aggressive uid resuscitation,
Mrs North’s calcium is rechecked, and it has gone
down to 2.8 mmol/L.
Mrs North is reviewed by the oncology consultant and palliative care specialist nurse on the
ward in the aernoon. e consultant explains
that due to her extensive disease, unfortunately
active management would not be appropriate.
Aer a long and dicult discussion, Mrs North
agrees not to undergo any further active treatment. e palliative nurse suggests that she consider going to a hospice for symptom control as
she is still requiring signicant input to manage
her breathlessness. Mrs North agrees to this.
What medications should be
prescribed for a palliative
discharge?
‘Just in case’ or ‘anticipatory’ medications may be
given in hospital to patients nearing the end of life
to help with symptom management. Patients may
also be given the medications to go home with (to
be administered by a district nurse) or if they are
going to a hospice as a palliative discharge. ese
medications can be given subcutaneously when
needed or through a syringe driver. Most trusts
will have a guideline regarding their preferred
choices for anticipatory prescribing, but Table
17.1 summarises some of the common medications used and their doses. Remember that elderly
or frail patients, or patients with renal or liver
impairment, may require reduced doses.
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Mrs North is discharged to the local hospice. She
passes away 2 weeks later. e hospice doctor is
called to conrm her death.
What is the process for confirming
the death of a patient?
●
Conrm the identity of the patient by checking their wristband
●
Observe for signs of life throughout
●
Check for a response to verbal and painful
stimulus
●
Check the appearance of the pupils (dilated
and xed with no response to light)
●
Assess for 3 minutes in total for the presence of
●
Respiratory sounds on auscultation
●
Heart sounds on auscultation
●
Carotid or other central pulse
●
It is good practice to palpate for a pacemaker
as these need to be removed if the patient has
requested to be cremated
●
Document the time and date of death
●
If possible, document who was present at time
of death
●
Include your name, designation and GMC
number
Case 18
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TIMEPOINT 1
Mrs Moloney is a 64-year-old cleaner who presents to the emergency department as she has been
feeling unwell all week, and when she checked
her temperature at home had a fever of 38.7°C.
She has had a cough and shortness of breath for
6 days and was started on antibiotics for a presumed chest infection by her GP 4 days ago.
However, she feels that her condition has been
deteriorating despite the antibiotics, and she has
now started coughing up thick green sputum. She
denies chest pain, weight loss and haemoptysis.
Her only past medical history is type 2 diabetes, for which she takes metformin 1 g BD. She
has never smoked and drinks only 1 or 2 small
glasses of wine a night. She spent a week in Spain
around 8 months ago, but has not travelled since
then.
Mrs Moloney has already been put on 24%
oxygen by the triage nurse.
Her observations show:
Respiratory rate: 24/min
Oxygen saturations: 97% on 24% oxygen
Temperature: 38.4°C
Blood pressure: 132/59 mmHg
Heart rate: 88 bpm
Her heart sounds are normal, but she has
decreased expansion over the right hemithorax,
with a stony dull percussion note, reduced breath
sounds and reduced vocal resonance at the right
base. Abdominal and neurological examination
are unremarkable.
e emergency doctor is concerned that Mrs
Moloney may have developed a pleural effusion
as a result of a chest infection.
What investigations should be
arranged at this stage?
Bloods
FBC – infection, anaemia
U&Es – baseline cause of effusion
CRP – infection
LFTs – atypical pneumonia, liver failure
as cause of effusion
BNP – heart failure
Chest X-ray
Initial blood test results are given in Table 18.1.
e chest radiograph shows a moderate-sized,
right-sided pleural effusion.
Table 18.1 Venous blood tests
Haemoglobin 126 g/L
9
White cell count 14.3 × 10
Neutrophils 11.2 × 10
Lymphocytes 1.4 × 10
Platelets 464 × 10
Sodium 136 mmol/L
Potassium 3.9 mmol/L
Urea 7.4 mmol/L
Creatinine 87 µmol/L
Bilirubin 13 µmol/L
ALT 29 U/L
AST 26 U/L
Albumin 37 g/L
Protein 72 g/L
Glucose 5.9 mmol/L
CRP 112 mg/L
LDH 210 U/L
/L
9
/L
9
/L
9
/L
DOI: 10.1201/9781351257725-18
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In light of the initial investigation
findings, what further investigations
should be arranged?
An ultrasound-guided pleural aspiration should
be arranged. It is important to check that the
patient has a normal clotting profile first.
When sending a pleural aspiration,
what tests should be requested?
Samples should be sent for the following:
Biochemistry: protein, LDH, glucose, lactate
Microbiology: MC&S, acid fast bacilli staining and culture
pH
Cytology
In some hospitals, it is possible to check glucose,
lactate and pH on a blood gas analyser to get
instant point of care results.
TIMEPOINT 2
Two hours later, Mrs Moloney has been admitted
to the ward. e ward doctor is able to see some of
the preliminary results which are available from
the pleural aspiration.
Results of pleural aspiration
Protein 44 g/L
LDH 315 U/L
Glucose 3.1 mmol/L
pH 7.42
Into which two categories can
pleural effusions be divided?
Discuss the criteria used to
distinguish between the categories.
Pleural fluid protein/serum protein ratio >0.5
Pleural fluid LDH/serum LDH ratio >0.6
Pleural fluid LDH >2/3 of the upper limit of
normal for serum LDH
Transudates are caused by decreased oncotic pressure or increased hydrostatic pressure. Common
causes of transudates are le ventricular failure,
nephrotic syndrome and liver cirrhosis. Exudates
are caused by increased capillary permeability. Common causes of exudates are infections,
malignancy and connective tissue disease.
How should Mrs Moloney be
managed?
Mrs Moloney’s pleural effusion is an exudate,
with a history and test results suggestive of a
parapneumonic effusion. She therefore requires
appropriate antibiotic treatment.
e ward doctor starts Mrs Moloney on IV coamoxiclav 1.2 g TDS and oral clarithromycin
500 mg BD, in accordance with local microbiology guidelines.
TIMEPOINT 3
Five days aer admission, the ward doctor is
called to see Mrs Moloney as she is spiking a temperature of 39.2°C, despite having taken 4 days
of intravenous antibiotics. She asks the nurse to
repeat her observations.
Her observations show:
Respiratory rate: 28/min
Oxygen saturations: 94% on 2 L oxygen via nasal
cannulae
Temperature: 39.2°C
Blood pressure: 104/75 mmHg
Heart rate: 124 bpm
Pleural effusions can be divided into transu-
dates and exudates using Light’s criteria.
Pleural fluid is considered to be exudative if it
meets any of the following criteria:
On examination, she still has a dull-sounding
right base with coarse crackles in the midzone.
e doctor requests a repeat chest X-ray. See
Figures 18.1 and 18.2.
Figure 18.1 The chest X-ray shows a right sided
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pleural effusion, which appears more complex;
suggestive of an empyema.
Case 18: Timepoint 4 93
Later that eveni ng, the microbiolog y lab phones
through to the ward to inform them that pus cells
have been seen in Mrs Moloney’s pleural fluid.
What is the diagnosis, and how
should Mrs Moloney be managed?
Pus cells in the pleural fluid are indicative of an
empyema. Empyema has a 15% mortality rate,
so senior-led management is important. e pus
needs to be drained from the pleural space. is
can oen be done with a chest drain, but up to
30% require surgical drainage via thoracoscopy
(VATS). e case should be discussed with a
thoracic surgeon. VATS has no mortality benefit
over simple chest drain insertion, but does reduce
length of admission. CT imaging will allow a better assessment of the degree of loculation, and
will inform the decision as to whether to manage with VATS. e evidence suggests that flushing the chest drain with fibrinolytics does not
improve the outcome.
Appropriate antibiotic therapy should be
discussed with a microbiologist and should be
guided by microscopy, culture and sensitivity
of the pleural fluid. e organism responsible
for the empyema is usually the same organism
responsible for the pneumonia, and knowledge of
local conditions should guide empiric treatment.
Aminoglycosides (e.g. gentamicin, streptomycin) are not effective at low pH and should not
be used. Duration of antibiotic therapy should
be guided by the identity of the organism and its
sensitivities, and by clinical response. Oen 4–6
weeks is recommended.
Figure 18.2 The white outline on the same
image (Figure 18.1) demarcates the loculated
nature of the effusion. Generally, empyemas
tend to form a lenticular shape (biconvex)
against the chest wall.
Aer viewing the results, the ward doctor calls
the on-call respiratory registrar who agrees to
help with a pleural aspiration. ick, cloudy fluid
is aspirated from the pleural space under ultrasound guidance.
TIMEPOINT 4
Two hours later, the night-shi medical registrar
receives a handover from the day team that an
urgent chest drain is required for an empyema.
Unfortunately, it was not done during the evening shi as the team was busy attending to a
peri-arrest patient.
e medical registrar prepares their equipment for the chest drain and consents Mrs
Moloney.
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What are the complications of chest
drain insertion?
Pain
Failed procedure (incorrectly sited)
Bleeding
Infection
Pneumothorax
Haemothorax
Damage to intercostal nerve
Pulmonary oedema
Organ damage
e registrar explains the procedure, including
the risks and benefits, and answers all of Mrs
Moloney’s questions. She agrees to go ahead with
the procedure.
e registrar sets up his sterile field, cleans
the area for insertion and gives local anaesthetic. He then inserts the needle into the pleural space and advances the guidewire. He makes
a small incision and then passes the dilator over
the guidewire, and then finally passes the chest
drain over the guidewire. As soon as the tubing is
connected, frank blood is seen in the tubing. e
blood pressure machine shows 78/43 mmHg. e
tube continues to drain blood and Mrs Moloney
stops responding. e doctor pulls the emergency
buzzer and a nurse quickly runs in with a crash
trolley. e healthcare assistant puts out a crash
call whilst the registrar and the nurse commence
advanced life support.
Hypoxia
Hypovolaemia
Hypokalaemia/hyperkalaemia/other metabolic derangement
Hypothermia
Toxins
Tension pneumothorax
Tamponade (cardiac)
Thrombosis (coronary or pulmonary)
e likely causes in this scenario are either a cardiac tamponade or a hypovolaemic arrest.
e rest of the crash team arrive and continue
advanced life support. A bedside ultrasound
scan shows no evidence of tamponade, so Mrs
Moloney is treated as a hypovolaemic arrest secondary to iatrogenic large vessel trauma from the
chest drain insertion. Unfortunately, despite the
best efforts of the team, they are unable to resuscitate Mrs Moloney, and aer six cycles the decision is made to stop.
FURTHER READING
1. Case study with parallels to Timepoint4:
VignauCano J.M., Bermúdez García
A., Macías Rubio D. Lesión de aorta
torácica portubo pleural. Med
Intensiva. 2019;43:192. DOI: 10.1016/j.
medine.2019.01.005
What reversible causes should be
considered during advanced life
support? What are the likely causes
in this case?
e causes can be summarised as the 4 Hs and
the 4 Ts.
Case 19
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TIMEPOINT 1
Mr Williams is a 58-year-old plumber who
attends his GP complaining of a cough. He is
starting to worry that the cough has been going
on for too long which is why he has presented
today. He guesses that it has been going on for
at least 6 months now, but probably less than a
year. e cough is sometimes productive, but the
sputum is always clear. He denies being breathless at rest, although he admits that he is increasingly breathless on exertion which is starting to
interfere with his work. He also struggles to keep
up with his wife when they are out walking. He
denies having any chest pain, any difficulty sleeping due to breathlessness or any weight loss. He
has never coughed up any blood.
In terms of past medical history, Mr Williams
has well-controlled hypertension. He has also had
adhesive capsulitis of the le shoulder in the past,
and a right-sided Colles’ fracture many years
ago. e GP notes that over the last few years Mr
Williams has seemed to present recurrently in the
winter months with respiratory tract infections
and has received numerous courses of antibiotics for these. He takes ramipril 5 mg daily, and
has no allergies that he is aware of. He drinks a
couple of pints of lager each evening at the pub,
and smokes around 30–40 cigarettes a day. He
says that he has been smoking for 40 odd years
now so is really struggling to cut down, although
he knows that he should.
On examination he appears well, with no
obvious signs of respiratory distress.
His observations are:
Respiratory rate: 22/min
Oxygen saturations: 94% on room air
Temperature: 36.6°C
Blood pressure: 129/85 mmHg
Heart rate: 84 bpm
On examination, he is warm and well perfused
peripherally with a capillary refill time of less
than 2 seconds and no evidence of cyanosis. His
pulse is approximately 80 beats per minute and
regular. His JVP is not raised. His trachea is central with a reduced cricosternal distance. On auscultation, wheezing can be heard throughout the
lung fields, but no crepitations. ere is no evidence of sacral or pedal oedema.
e GP wonders if COPD might be a good
explanation for Mr Williams’ symptoms, given
his extensive smoking history.
What initial investigations should be
carried out if COPD is suspected?
Calculation of BMI
Full blood count to assess for anaemia or
polycythaemia
Chest X-ray to exclude other lung pathologies
Spirometry, including post-bronchodilator
testing, should be performed at diagnosis
Sputum culture should be considered in order
to identify organisms if sputum is purulent
Serial peak flow measurements should be
considered in order to exclude asthma if there
is still uncertainty regarding the diagnosis
ECG, BNP and echo should be considered if
there is a history of cardiovascular disease or
features of pulmonary hypertension
Serum alpha-1 antitrypsin should be consid-
ered if the patient is younger than 35 years,
or has a minimal smoking history, or has a
family history of lung disease
DOI: 10.1201/9781351257725-19
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What advice could Mr Williams be
given regarding smoking cessation,
irrespective of his spirometry
results?
Smoking cessation is a key element of lifestyle
management of COPD
Patients with COPD should be offered smoking cessation advice at every healthcare
contact
is may include brief advice, behavioural
support, nicotine replacement therapy, varenicline or bupropion if needed
Current evidence suggests that e-cigarettes are
significantly less dangerous than smoking but
are not completely risk-free, and the long-term
impact of their use is still unknown
If a patient is not yet ready to stop smoking,
remind them again of the benefits of stopping
and encourage them to seek help in the future
when they feel more ready
The GP discusses smoking cessation with Mr
Williams, and he agrees to try a course of varenicline and referral to a behavioural support
programme. She prescribes him a salbutamol inhaler to use as required, and refers him
for spirometry at the local hospital. She also
requests that he be assessed for pulmonary
rehabilitation.
TIMEPOINT 2
One week later, the GP reviews Mr Williams’ spirometry results.
What would you expect to see on
spirometry?
You would expect to see evidence of obstructive airway disease, defined as a post-bronchodilator FEV1/
FVC <0.7. Severity can then be stratified using the
FEV1 as a percentage of the predicted value.
Spirometry is an important tool both for diagnosis but also for the monitoring of disease progression. Although the level of airway obstruction
does not correlate well with the extent of the
patient’s disability, it helps to guide treatment and
estimate prognosis.
Spirometry demonstrates an FEV1/FVC of 0.63
and FEV1 58% of predicted.
e GP phones Mr Williams to ask him how
he is getting on. He reports that he does not think
the blue inhaler has helped him very much. He
has been using it 6–7 times a day when he feels
breathless on exertion, but it doesn’t seem to
make much difference. e GP explains that
the spirometry confirms a diagnosis of COPD,
and suggests starting a LAMA-LABA inhaler.
She also asks him to book an appointment for
influenza and pneumococcal vaccinations. Mr
Williams is happy with this plan.
How should inhalers be escalated (Figure 19.1)?
ICS = inhaled corticosteroid
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Case 19: Timepoint 2 97
Step 1
Step 2
Step 3
Step 4
Step 5
Optimise patient
Inuenza + pneumococcal vaccinations
Short-acting bronchodilators
DO NOT have asthmatic features or
features suggesting steroid responsiveness
Long-acting bronchodilators
DO have asthmatic features or features
suggesting steroid responsiveness
Breathless or exacerbations despite LABA-ICS
Triple therapy
Home nebulisers – if distressing symptoms despite maximal inhaler therapy
Oral steroids – if unable to wean following exacerbation
Oral theophylline – if unable to use, or poor response to inhalers
Oral mucolytics – if chronic productive cough
Oral prophylactic antibiotics – if recurrent infections
Roumilast – a monoclonal antibody used as an add on bronchodilator
Smoking cessation
Pulmonary rehabilitation
SABA e.g. salbutamol
SAMA e.g.ipratropium
LAMA-LABA e.g
tiotropium-olodaterol
LABA-ICS e.g
budesonide-formoterol
LAMA-LABA-ICS
Provide a spacer
Inhaler technique
KEY:
SABA = short-acting beta-2 agonist
SAMA = short-acting muscarinic agonist
LABA = long-acting beta-2 agonist
LAMA = long-acting muscarinic agonist
Figure 19.1 Escalation of treatment in COPD.
Surgical options for severe COPD
Lung volume reduction
Bullectomy
Lung transplant
How can COPD be staged?
Either using post-bronchodilatory FEV1 (GOLD
scale) (Table 19.1) or using the MRC dyspnoea
scale (Table 19.2).
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