Core Clinical Cases in Medicine and Medical Specialties This page intentionally left blank Core Clinical Cases in Medicine and Medical Specialties Second edition Edited by Steve Bain MA MD FRCP Professor of Medicine (Diabetes), Institute of Life Sciences, Swansea University, Swansea Honorary Consultant Physician, ABM University Health Board, Singleton Hospital, Swansea Jeffrey W Stephens BSc MBBS PhD FRCP Professor of Medicine (Diabetes and Metabolism), Institute of Life Sciences, Swansea University, Swansea Consultant Physician, Morriston Hospital, ABM University Health Board, Swansea Core Clinical Cases series edited by Janesh K Gupta MSc MD FRCOG Professor in Obstetrics and Gynaecology, University of Birmingham, Birmingham Women’s Hospital, Birmingham, UK First published in Great Britain in 2006 by Hodder Arnold This second edition published 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 Steve Bain and Jeffrey Stephens All rights reserved. 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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 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: 978-1-4441-4542-7 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Joanna Koster Project Editor: Stephen Clausard Production Controller: Joanna Walker Cover Design: Amina Dudhia Indexer: Lisa Footitt Typeset in 9 on 11pt Frutiger by Phoenix Photosetting, Chatham, Kent Printed and bound by CPI Group (UK) Ltd., Croydon, CR0 4YY. What do you think about this book? Or any other Hodder Arnold title? Please visit our website: www.hodderarnold.com Contents Contributors vii Series preface ix Abbreviations xi Chapter 1 Diabetes 1 Steve Bain Diagnosis 3 Glucose control for patients with diabetes mellitus 11 Diabetic small vessel complications 19 Diabetic large vessel complications 27 Diabetes emergencies 34 Chapter 2 Endocrinology 43 Andrew Levy Hyperthyroidism 45 Addison’s disease (autoimmune adrenal failure) 51 Cushing’s disease 56 Acromegaly 62 Chapter 3 Rheumatology 67 Mark Pugh Polyarthritis 69 Monoarthritis 76 Systemic rheumatological illnesses 83 Back pain 90 Chapter 4 Renal medicine 97 Indranil Dasgupta Renal emergencies 98 Renal case studies 105 Chronic kidney disease 113 Chapter 5 Cardiology 117 Morgan Cadman-Davies, Nevianna Tomson and Neeraj Prasad Chapter 6 Care of elderly people 137 Peter Wallis Falls 139 Immobility 149 Acute confusional states 159 Incontinence 168 Iatrogenic illness in frail older patients 176 Chapter 7 Respiratory medicine 183 Malcolm Shepherd Dyspnoea 185 vi Contents Pleuritic chest pain 193 Haemoptysis 201 Chapter 8 Gastroenterology 209 C.S. Probert Gastroenterological emergencies 212 Pancreatitis 220 Inflammatory bowel disease 227 Peptic ulcer disease 234 Cirrhosis 241 Constipation 248 Hepatitis 255 Irritable bowel syndrome 261 Coeliac disease 268 Chapter 9 Haematology 275 Christopher Fegan Anaemia 277 Abnormal full blood count 285 Haemoglobinopathies 294 Chapter 10 Oncology emergencies 303 Daniel Rea Chapter 11 Neurology 313 Stuart Weatherby Disorders of consciousness 315 Cerebrovascular disease 326 Diseases of peripheral nerves 329 Headache 334 Central nervous system demyelination 344 Disorders of cranial nerves 347 Movement disorders 351 Miscellaneous neurological disorders 354 Chapter 12 Infectious diseases 363 Chris Ellis Chapter 13 Dermatology 375 Nevianna Tomson Malignant melanoma 377 Non-melanoma skin cancer 384 Eczema 391 Psoriasis 397 Pruritus 403 Acne 409 Index 415 Contributors Steve Bain MA MD FRCP Professor of Medicine (Diabetes), Institute of Life Sciences, Swansea University, Swansea Honorary Consultant Physician, ABM University Health Board, Singleton Hospital, Swansea Morgan Cadman-Davies MBChB ST1 General Practice Trainee, Hereford County Hospital, Hereford Indranil Dasgupta MBBS MD DM FRCP Consultant Nephrologist and Honorary Senior Lecturer, Birmingham Heartlands Hospital, Birmingham Chris Ellis MB FRCP DTM&H Consultant in Infectious Diseases, Birmingham Heartlands Hospital, Birmingham Christopher Fegan MBBS MD FRCP FRCPath Consultant Haematologist, Llandough Hospital, Cardiff Andrew Levy PhD FRCP Professor of Medicine, Bristol University, Bristol Honorary Consultant Physician, Bristol Royal Infirmary, Bristol Neeraj Prasad MD FRCP Consultant Cardiologist, Hereford County Hospital, Hereford C.S. Probert MD FRCP FHEA Professor of Gastroenterology, Department of Gastroenterology, Institute of Translational Medicine, University of Liverpool, Liverpool Mark Pugh DTM DCH MD FRCPI Consultant Rheumatologist and Clinical Tutor, Department of Rheumatology, St Mary’s Hospital, Newport, Isle of Wight Daniel Rea MBBS BSc PhD FRCP Senior Lecturer in Medical Oncology, University of Birmingham, Birmingham Malcolm Shepherd MBChB MRCP PhD Balmforth Intermediate Clinical Scientist Research Fellow, University of Glasgow, Glasgow Nevianna Tomson MBChB MRCP Consultant Dermatologist, West Suffolk Hospital, Bury St Edmunds Peter Wallis MBBS FRCP Consultant Geriatrician and Honorary Senior Clinical Lecturer, University of Birmingham, Department of Elderly Medicine, Birmingham Heartlands Hospital, Birmingham Stuart Weatherby MBChB MRCP MD Consultant Neurologist, Derriford Hospital, Plymouth Honorary University Fellow to the Peninsula Medical School, Plymouth This page intentionally left blank Series preface ‘A history lesson’ Between about 1916 and 1927 a puzzling illness appeared and swept around the world. Dr von Economo first described encephalitis lethargica (EL), which simply meant ‘inflammation of the brain that makes you tired’. Younger people, especially women, seemed to be more vulnerable, but the disease affected people of all ages. People with EL developed a ‘sleep disorder’, fever, headache and weakness, which led to a prolonged state of unconsciousness. The EL epidemic occurred during the same period as the 1918 influenza pandemic, and the two outbreaks have been linked ever since in the medical literature. Some people confused it with the epidemic of Spanish flu at that time, while others blamed weapons used in the First World War. Encephalitis lethargica was dramatized by the film Awakenings, based on the book written by Oliver Sacks, an eminent neurologist from New York, and starring Robin Williams and Robert De Niro. Professor Sacks treated his patients with l-dopa, which temporarily awoke his patients, giving rise to the belief that the condition was related to Parkinson’s disease. Since the 1916–1927 epidemic, only sporadic cases of EL have been described. Pathological studies have revealed an encephalitis of the midbrain and basal ganglia, with lymphocyte (predominantly plasma cell) infiltration. Recent examination of archived EL brain material has failed to demonstrate influenza RNA, adding to the evidence that EL was not an invasive influenza encephalitis. Further investigations found no evidence of viral encephalitis or other recognized causes of rapid-onset parkinsonism. Magnetic resonance imaging of the brain was normal in 60 per cent but showed inflammatory changes localized to the deep grey matter in 40 per cent. As late as the end of the twentieth century, it seemed that the possible answers lay in the clinical presentation of the patients in the 1916–1927 epidemic. It had been noted by the clinicians at that time that the central nervous system (CNS) disorder had presented with pharyngitis. This led to the possibility of a post-infectious autoimmune CNS disorder similar to Sydenham’s chorea, in which group A beta- haemolytic streptococcal antibodies cross-react with the basal ganglia and result in abnormal behaviour and involuntary movements. Anti-streptolysin-O titres have subsequently been found to be elevated in the majority of these patients. It seemed possible that autoimmune antibodies may cause remitting parkinsonian signs subsequent to streptococcal tonsillitis as part of the spectrum of post-streptococcal CNS disease. Could it be that the 80-year-old mystery of EL has been solved by relying on the patient’s clinical history of presentation rather than focusing on expensive investigations? More research in this area will give us the definitive answer. This scenario is not dissimilar to the controversy about the idea that streptococcal infections were aetiologically related to rheumatic fever. With this example of a truly fascinating history lesson, we hope you will endeavour to use the patient’s clinical history as your most powerful diagnostic tool to make the correct diagnosis. If you do, you are likely to be right 80–90 per cent of the time. This is the basis of the Core Clinical Cases series, which will make you systematically explore clinical problems through the clinical history of presentation, followed by examination and then the performance of appropriate investigations. Never break those rules! Janesh Gupta