Материал: 100_Cases_in_Clinical_Medicine

ANSWER 47

A number of features in the history make oesophageal reflux a likely diagnosis. The character and position of the pain and the relation to lying flat and to bending mean reflux is more likely. She is overweight, increasing the likelihood of reflux. The improvement with glyceryl trinitrate and with proprietary antacids is inconclusive. The ECG shows one ventricular ectopic and some T-wave changes in leads I, aVl, V5 and V6 which would be compatible with myocardial ischaemia but are not specific. The exercise ECG was negative which reduces the likelihood of ischaemic heart disease although it certainly does not rule it out. Other causes of chest pain are less likely with the length of history.

In view of the long history and the features suggesting oesophageal reflux, it would be reasonable to initiate a trial of therapy for oesophageal reflux with regular antacid therapy, H2-receptor blockers or a proton pump inhibitor (omeprazole or lansoprazole). If the pain responds to this form of therapy, then additional actions such as weight loss (she is well above ideal body weight) and raising the head of the bed at night should be added. If doubt remains, a barium swallow should show the tendency to reflux and a gastroscopy would show evidence of oesophagitis. There is a broad association between the presence of oesophageal reflux, evidence of oesophagitis at endoscopy and biopsy, and the symptoms of heart burn. However, each can occur independently of the others.

Recording of pH in the oesophagus over 24 h can provide additional useful information. It is achieved by passing a small pH-sensitive electrode into the oesophagus through the nose. This provides an objective measure of the amount of acid reaching the oesophagus and the times when this occurs.

This woman had an endoscopy which showed oesophagitis, and treatment with omeprazole and an alginate relieved her symptoms. Attempts at weight loss were not successful.

KEY POINTS

•In non-specific chest pain with a normal ECG, the oesophagus is a common source of the pain.

•24-h pH recording in the oesophagus provides further information on acid reflux.

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CASE 48: HEADACHES

History

A 44-year-old woman presents to her general practitioner (GP) complaining of headaches. These headaches have been present in previous years but have now become more intense. She describes the headaches as severe and present on both sides of her head. They tend to worsen during the course of the day. There is no associated visual disturbance or vomiting. She also complains of loss of appetite and difficulty sleeping, with early morning waking. She has had eczema and irritable bowel syndrome diagnosed in the past but these are not giving her problems at the moment. She is divorced with two children aged 10 and 12 years, whom she looks after. She has a part-time job as an office cleaner. Her mother has recently died of a brain tumour. She smokes about 20 cigarettes per day and drinks 15 units of alcohol per week. She takes regular paracetamol or ibuprofen for her headaches.

Examination

She looks withdrawn. Her pulse is 74/min and regular, blood pressure is 118/76 mmHg. Examination of the cardiovascular, respiratory and gastrointestinal systems, breasts and reticuloendothelial system is normal. There are no abnormal neurological signs and funduscopy is normal.

Questions

•What is the diagnosis?

•What are the major differential diagnoses?

•How would you manage this patient?

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ANSWER 48

This patient has a chronic tension headache. This is the commonest form of headache. It occurs mainly in patients under the age of 50 years. The headache is usually bilateral, often with diffuse radiation over the vertex of the skull, although it may be more localized. The pain is often characterized as a sense of pressure on the head. Visual symptoms and vomiting do not occur. The pain is often at its worst in the evening. Patients may show symptoms of depression (this woman has biological symptoms of loss of appetite and disturbed sleep pattern). Sufferers may reveal sources of stress such as bereavement or difficulty with work. There may be an element of suggestion as in this case, with concern that she may have inherited a brain tumour from her mother. She is looking after two children alone and working part-time. A normal neurological examination is important for reassurance.

!Major differential diagnoses of chronic headaches

•Classic migraine: characterized by visual symptoms followed within 30 min by the onset of severe hemicranial throbbing, headache, photophobia, nausea and vomiting lasting for several hours. The onset is usually in early adult life and a positive family history may be present.

•Cluster headaches: mainly affect men. The pain is unilateral, usually orbital and severe in nature. It characteristically occurs 1–2 h after sleeping, and lasts 1–2 h and recurs nightly for 6–8 weeks.

•Headache caused by a space-occupying lesion (such as tumour or abscess): Often the headache is initially mild but over a few weeks becomes severe and is exacerbated by coughing or sneezing. The headache is usually worse in the morning and is associated with vomiting. There will often be other signs, including personality change and focal neurological signs.

•Miscellaneous causes: sinusitis, dental disorders, cervical spondylosis, glaucoma, post-traumatic headache.

It is important to come to a clear diagnosis and to address the patient’s beliefs and concerns about the symptoms. In some circumstances it may be necessary to perform a computed tomography (CT) head scan for reassurance. The question of depression needs to be explored further and may need treating with antidepressants.

KEY POINTS

•Tension headaches occur mainly in those aged under 50, and patients often show features of depression.

•Tension headache should be diagnosed after other causes have been excluded.

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CASE 49: HEADACHE AND CONFUSION

History

A 55-year-old man is admitted to hospital with headache and confusion. He has a cough and a temperature of 38.2°C. He does not complain of any other symptoms. Two months earlier he had been admitted with a productive cough and acid-fast bacilli had been found in the sputum on direct smear. He had lost weight and complained of occasional night sweats. He had a history of a head injury 10 years previously. He smoked 15 cigarettes a day and drank 40–60 units of alcohol each week. He was found a place in a local hostel for the homeless and sent out after 1 week in hospital on antituberculous treatment with rifampicin, isoniazid, ethambutol and pyrazinamide together with pyridoxine. His chest X-ray at the time was reported as showing probable infiltration in the right upper lobe.

Examination

He looked thin and unwell and he was slightly drowsy. His mini mental test score was 8/10. There were some crackles in the upper zones of the chest posteriorly. His respiratory rate was 22/min. There were no neurological signs.

INVESTIGATIONS

His chest X-ray is shown in Fig. 49.1.

Figure 49.1 Chest X-ray.

Question

• What might be the cause of his second admission?

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ANSWER 49

The chest X-ray shows extensive changes in the right upper zone which seem as if they are likely to be more extensive than those described at the first admission 2 months earlier. It is likely that this is a worsening of his pulmonary tuberculosis. This might have occurred because he had a resistant organism or, more likely, because he had not taken his treatment as prescribed. Risk factors for development of tuberculosis are poor nutrition, high alcohol intake and immunosuppression (HIV, immunosuppressive therapy). Higher rates occur in those from the Indian subcontinent and parts of Africa.

The headache and confusion raise the possibility of tuberculous meningitis. Other possibilities would be liver damage from the antituberculous drugs and the alcohol, although clinical jaundice would be expected, or electrolyte imbalance. If these are not present a lumbar puncture would be indicated, provided that there is no sign to suggest raised intracranial pressure. It would be advisable to do a computed tomography (CT) scan of the brain first since a fall related to his high alcohol consumption might have led to a subdural haemorrhage to give him his headache and confusion.

It is now 2 months since the initial finding of acid-fast bacilli in the sputum and the cultures and sensitivities of the organism should now be available. These should be checked to be sure that the organism was Mycobacterium tuberculosis and that it was sensitive to the four antituberculous drugs which he was given. As a check on compliance, blood levels of antituberculous drugs can be measured. The urine will be coloured orangy-red by metabolites of rifampicin taken in the last 8 h or so.

Comparison with his old chest X-rays showed extension of the right upper-lobe shadowing. It is difficult to be sure about activity from a chest X-ray but extension of shadowing is obviously suspicious. ‘Softer’ more fluffy shadowing is more likely to be associated with active disease. A direct smear of the sputum showed that acid-fast bacilli were still present on direct smear. He confirmed that he was not taking his medication regularly. His headache and confusion resolved as he stopped his high alcohol intake. Subsequently the antituberculous therapy should be given as directly observed therapy (DOT) in a thriceweekly regime supervised at each administration by a district nurse or health visitor.

KEY POINTS

•Poor adherence to treatment regimes is the commonest cause of failure of antituberculous and other treatment.

•Directly observed therapy should be used when there is any doubt about adherence to treatment.

•Four drugs should be used (rifampicin, isoniazid, pyrazinamide and ethambutol) when there is a higher risk of resistant organisms, e.g. immigrants from Africa, Asia, previously treated patients, patients of no fixed abode.

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