Материал: 100_Cases_in_Clinical_Medicine
CASE 69: ABDOMINAL PAIN
History
A 58-year-old woman consults her general practitioner (GP) with a 2-month history of intermittent dull central epigastric pain. It has no clear relationship to eating and no radiation. Her appetite is normal, she has no nausea or vomiting and she has not lost weight. Her bowel habit is normal and unchanged. There is no relevant past or family history. She has never smoked, and drinks alcohol very rarely. She has worked all her life as an infant school teacher. Physical examination at this time was completely normal, with a blood pressure of 128/72 mmHg. Investigations showed normal full blood count, urea, creatinine and electrolytes, and liver function tests.
An H2 antagonist was prescribed and follow-up advised if her symptoms did not resolve. There was slight relief at first, but after 1 month the pain became more frequent and severe, and the patient noticed that it was relieved by sitting forward. It had also begun to radiate through to the back. Despite the progressive symptoms she and her husband went on a 2-week holiday to Scandinavia which had been booked long before. During the second week her husband remarked that her eyes had become slightly yellow, and a few days later she noticed that her urine had become dark and her stools pale. On return from holiday she was referred to a gastroenterologist.
Examination
She was found to have yellow sclerae with a slight yellow tinge to the skin. There was no lymphadenopathy and her back was normal. As before her heart, chest and abdomen were normal.
INVESTIGATIONS
Haemoglobin |
15.3 g/dL |
11.7–15.7 g/dL |
White cell count |
6.2 % 109/L |
3.5–11.0 % 109/L |
Platelets |
280 % 109/L |
150–440 % 109/L |
Sodium |
140 mmol/L |
135–145 mmol/L |
Potassium |
4.8 mmol/L |
3.5–5.0 mmol/L |
Urea |
6.5 mmol/L |
2.5–6.7 mmol/L |
Creatinine |
111 &mol/L |
70–120 &mol/L |
Calcium |
2.44 mmol/L |
2.12–2.65 mmol/L |
Phosphate |
1.19 mmol/L |
0.8–1.45 mmol/L |
Total bilirubin |
97 mmol/L |
3–17 mmol/L |
Alkaline phosphatase |
1007 IU/L |
30–300 IU/L |
Alanine aminotransferase |
38 IU/L |
5–35 IU/L |
Gamma-glutamyl transpeptidase |
499 IU/L |
11–51 IU/L |
Questions
•What is the likely diagnosis?
•What further investigations should be performed?
179
ANSWER 69
The patient has an obstructive jaundice as indicated by the history of dark urine and pale stools and the liver function tests. The pain has two typical features of carcinoma of the pancreas: relief by sitting forward and radiation to the back. An alternative diagnosis could be gallstones but the pain is not typical.
As with obstruction of any part of the body the objective is to define the site of obstruction and its cause. The initial investigation was an abdominal ultrasound which showed a dilated intrahepatic biliary tree, common bile duct and gallbladder but no gallstones. The pancreas appeared normal, but it is not always sensitive to this examination owing to its depth within the body.
Further investigation of the region at the entrance of the common bile duct into the duodenum and head of the pancreas was indicated and was undertaken by computed tomography (CT) scan. It showed a small tumour in the head of the pancreas causing obstruction to the common bile duct, but no extension outside the pancreas. No abdominal lymphadenopathy was seen. No hepatic metastases were seen on this investigation or on the ultrasound.
The patient underwent partial pancreatectomy with anastamosis of the pancreatic duct to the duodenum. The jaundice was rapidly relieved. Follow-up is necessary not only to detect any recurrence but also to treat any possible development of diabetes.
KEY POINTS
•Carcinoma of the pancreas can present with non-specific symptoms in its early stages.
•It is an important cause of obstructive jaundice.
•Patients who have had a partial removal of the pancreas are at risk of diabetes.
180
CASE 70: LEG WEAKNESS
History
A 24-year-old woman is attending her regular Sunday church service. During the singing of a hymn she suddenly fell to the ground without any loss of consciousness and told the other members of the congregation who rushed to her aid that she had a complete paralysis of her left leg. She was unable to stand and was taken by ambulance to the emergency department. She has no other neurological symptoms and is otherwise healthy. She has no relevant past or family history, is on no medication and has never smoked or drunk alcohol. She works as a sales assistant in a bookshop and until recently lived in a flat with a partner of 3 years’ standing until they split up 4 weeks previously. She has moved back in with her parents.
Examination
She looks well, and is in no distress; making light of her condition with the staff. The only abnormalities are in the nervous system. She is completely orientated and the Mini-mental State score is normal. The cranial nerves and the neurology of the upper limbs and right leg are normal. The left leg is completely still during the examination, and the patient is unable to move it on request. Tone is normal; co-ordination could not be tested because of the paralysis. Superficial sensation was completely absent below the margin of the left buttock and the left groin, with a clear transition to normal above this circumference at the top of the left leg. Vibration and joint position sense were completely absent in the left leg. There was normal withdrawal of the leg to nociceptive stimuli such as firm stroking of the sole and increasing compression of Achilles’ tendon. The superficial reflexes and tendon reflexes were normal and the plantar response was flexor.
Questions
•What is the diagnosis?
•How would you manage this case?
181
ANSWER 70
This patient has hysteria, now renamed as dissociative disorder. The clues to this are the cluster of:
•the bizarre complex of neurological symptoms and signs which do not fit neuroanatomical principles, e.g. the reflex responses and withdrawal to stimuli despite the paralysis
•the patient’s lack of concern, known by the French term of ‘la belle indifference’
•the onset in relation to stress, i.e. the loss of her partner
•secondary gain: removing herself from the parental home which is a painful reminder of her splitting from her partner.
None of these on its own is specific for the diagnosis but put together they are typical. In any case of dissociative disorder the diagnosis is one of exclusion; in this case the neurological examination excludes organic lesions. It is important to realize that this disorder is distinct from malingering and factitious disease. The condition is real to patients and they must not be told that they are faking illness or wasting the time of staff.
The management is to explain the dissociation – in this case it is between her will to move her leg and its failure to respond – as being due to stress, and that there is no underlying serious disease such as multiple sclerosis. A very positive attitude that she will recover is essential, and it is important to reinforce this with appropriate physical treatment, in this case physiotherapy.
The prognosis in cases of recent onset is good, and this patient made a complete recovery in 8 days.
Dissociative disorder frequently presents with neurological symptoms, and the commonest of these are convulsions, blindness, pain and amnesia. Clearly some of these will require full neurological investigation to exclude organic disease.
KEY POINTS
•Dissociative disorder frequently presents as a neurological illness.
•The diagnosis of dissociative disorder must be one of exclusion.
182
CASE 71: DROWSINESS
History
A 72-year-old woman develops a chest infection and is treated at home with doxycycline by her general practitioner (GP). She lives alone but one of her daughters, a retired nurse, moves in to look after her. The patient has a long history of rheumatoid arthritis which is still active and for which she has taken 7 mg of prednisolone daily for 9 years. She takes paracetamol occasionally for joint pain. There is no other relevant past or family history. When the GP visited he found the blood pressure to be 138/82 mmHg.
For 5 days since 2 days before starting the antibiotics she has been feverish, anorexic and confined to bed. Her daughter has made her drink plenty of fluids. On the fifth day she became drowsy and her daughter had increasing difficulty in rousing her, so she called an ambulance to take her to the emergency department.
Examination
She is small (assessed as 50 kg) but there is no evidence of recent weight loss. Her temperature is 38.8°C. She is drowsy and responds to commands, but will not answer simple questions. There is a global reduction in muscle tone but no focal neurological signs. Her pulse is 118/min, blood pressure 104/68 mmHg and the jugular venous pressure is not raised. There is no ankle swelling. In the chest there are bilateral basal crackles and wheezes. Her joints show slight active inflammation and deformity, in keeping with the history of rheumatoid arthritis.
INVESTIGATIONS
|
|
Normal |
Haemoglobin |
11.5 g/dL |
11.7–15.7 g/dL |
Mean corpuscular volume (MCV) |
86 fL |
80–99 fL |
White cell count |
13.2 % 109/L |
3.5–11.0 % 109/L |
Platelets |
376 % 109/L |
150–440 % 109/L |
Sodium |
125 mmol/L |
135–145 mmol/L |
Potassium |
4.7 mmol/L |
3.5–5.0 mmol/L |
Urea |
8.4 mmol/L |
2.5–6.7 mmol/L |
Creatinine |
131 &mol/L |
70–120 &mol/L |
Glucose |
4.8 mmol/L |
4.0–6.0 mmol/L |
Questions
•What is the diagnosis?
•How would you explain the abnormal investigations?
•How would you manage this case?
183