100 CASES in Acute Medicine This page intentionally left blank 100 CASES in Acute Medicine Kerry Layne Core Medical Trainee, Guy’s & St Thomas’ NHS Foundation Trust, London, UK Henry Fok Academic Clinical Fellow, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Adam Nabeebaccus Specialist Registrar, Cardiology, King’s College, London, UK 100 Cases Series Editor: Professor P John Rees MD FRCP Professor of Medical Education, King’s College London School of Medicine at Guy’s, King’s and St Thomas’ Hospitals, London, UK First published in Great Britain in 2012 by Hodder Arnold, an imprint of Hodder Education, a division of Hachette UK 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2012 Kerry Layne, Henry Fok and Adam Nabeebaccus All rights reserved Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic production in accordance with the terms of licences issued by the Copyright Licensing Agency In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed Furthermore, dosage schedules are constantly being revised and new side-effects recognized For these reasons the reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-13 978-1-4441-3519-0 10 Commissioning Editor: Project Editor: Production Controller: Cover Design: Indexer: Joanna Koster Jenny Wright Francesca Wardell Amina Dudhia Laurence Errington Typeset in 10/12pt RotisSerif by Phoenix Photosetting, Chatham, Kent Printed and bound in India by Replika What you think about this book? Or any other Hodder Arnold title? Please visit our website: www.hodderarnold.com CONTENTS Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Shortness of breath and a cough Collapse and confusion in a young woman Diarrhoea following antibiotics Swollen glands and hearing impairment Nose bleed (epistaxis) following an operation Worsening delirium Deliberate self-harm Lymphadenopathy and malaise The ill returning traveller 10 Delirium and urinary symptoms 11 Headache in pregnancy 12 Epigastric pain and vomiting 13 Severe pain in the legs 14 Chest pain radiating to the back 15 Shortness of breath 16 Recurrent abdominal pain 17 Haemoptysis in a returning traveller 18 Bloody diarrhoea 19 Drowsiness and headaches 20 Progressive lower limb weakness 21 Seizure and agitation 22 Substance misuse 23 Unilateral leg swelling 24 Vomiting caused by norovirus 25 Fever and sore throat 26 Blurred vision 27 Recurring dizziness with exercise 28 Palpitations and collapse 29 Ecchymosis 30 Petechiae and limb weakness 31 Generalized weakness and dysarthria 32 Dysphagia and shallow breathing 33 Blisters and itchy skin 34 Shortness of breath following a fall 35 Swelling of lower limbs 36 Haemoptysis and shortness of breath 37 Knee swelling and pain 38 Bleeding per rectum 39 Shortness of breath and pedal oedema 40 Sharp central chest pain 41 Fever in a returned traveller 42 Red eyes and sight impairment 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 v Contents Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case Case vi 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 Rash and flu-like symptoms Substance abuse and agitation Generalized rash and malaise Pruritic rash and alopecia Defective vision and eye pain Abdominal pain with malaise and fever Painful shoulder and malaise Facial rash A woman ‘off her legs’ Acute confusion Memory loss and unsteadiness Postoperative hypotension Drowsiness bordering on coma Anxiety with Graves’ disease Episodic anxiety and headache Shortness of breath in a returning traveller A fatigued college girl Haematuria and flank pain Bradycardia and malaise Bleeding gums and nose Palpitations and shortness of breath Petechial rash and loss of consciousness Wheeze and productive cough Wheeze and shortness of breath Coffee-ground vomiting Progressive dysphagia and muscle stiffness Respiratory distress and oedema Loss of pain sensation Shortness of breath in a returning traveller Confusion following a fall Apparent adverse drug reaction Constipation with confusion Chest pain after exertion Fevers, weight loss and night sweats Right-sided chest pain Shortness of breath in a young non-smoker Loss of consciousness in diabetes ‘Indigestion’ with radiating pain Suspected opiate overdose Steady deterioration in function Exacerbation of COPD Epistaxis and haemoptysis Collapse associated with a headache Jaundice and pruritis Abdominal pain, bruising and confusion Chest pain with fever, malaise and myalgia Deteriorating renal function Flu-like symptoms and generalized weakness Blurred vision with headache Severe abdominal pain and fever Self-limiting generalized seizures 85 87 91 93 95 97 99 101 103 105 109 113 117 121 125 128 133 137 141 145 149 153 157 161 165 169 173 177 181 186 189 192 197 199 201 205 209 211 215 219 221 225 227 231 233 237 241 245 247 251 253 Contents Case Case Case Case Case Case Case Index 94 Abdominal pain, diarrhoea and fever 95 Target-like rash and fever 96 Fever, photophobia and neck stiffness 97 Seizure 98 Back pain and weight loss 99 Abdominal pain following alcohol excess 100 Night sweats, polyuria and polydipsia 257 259 263 265 269 271 273 276 vii ACKNOWLEDGEMENTS Dr Mark Kinirons, ‘for making us laugh during times of stress’ CASE 1: SHORTNESS OF BREATH AND A COUGH History A 64-year-old Afro-Caribbean woman has presented to the emergency department She has been feeling generally unwell for several weeks and has become increasingly breathless over the last four days She describes a non-productive cough but denies any fevers or night sweats Her medical history is significant for a recent diagnosis of right-sided carcinoma of breast that was treated with a lumpectomy (removal of the tumour in the breast) and a course of chemotherapy Examination The woman has reduced breath sounds on the right side of her chest, with dullness to percussion Pulse oximetry applied to her finger shows a reading of 92 per cent on room air A chest X-ray is performed in the emergency department (Fig 1.1) Figure 1.1 Questions • What does the chest X-ray show? • How would you investigate the underlying cause? • What would be the best treatment to help this patient’s symptoms? .. .100 CASES in Acute Medicine This page intentionally left blank 100 CASES in Acute Medicine Kerry Layne Core Medical Trainee, Guy’s & St Thomas’ NHS Foundation... rate 12/min, SaO2 96 per cent on room air INVESTIGATIONS White cells Haemoglobin Platelets Sodium Potassium Urea Creatinine C-reactive protein Bilirubin Alanine aminotransferase Alkaline phosphatase... malaise The ill returning traveller 10 Delirium and urinary symptoms 11 Headache in pregnancy 12 Epigastric pain and vomiting 13 Severe pain in the legs 14 Chest pain radiating to the back 15 Shortness