Medicine and Surgery

Core
Clinical
Cases in Medicine
and Surgery
Core Clinical Cases
Titles in the series include:
Core Clinical Cases in Basic Biomedical Science

Author: Samy Azer
Core Clinical Cases in Medical and Surgical Specialties

Edited by Steve Bain & Janesh K. Gupta
Core Clinical Cases in Medicine and Surgery

Edited by Steve Bain & Janesh K. Gupta
Core Clinical Cases in Obstetrics & Gynaecology 2nd Edition

Authors: Janesh K. Gupta, Gary Mires & Khalid S. Khan
Core Clinical Cases in Paediatrics

Authors: Andrew Ewer, Timothy G. Barrett & Vin Diwakar
Core Clinical Cases in Psychiatry

Authors: Tom Clark, Ed Day & Emma C. Fergusson
Core
Clinical
Cases in Medicine
and Surgery
a problem-solving approach
Edited by
Steve Bain MA MD FRCP
Professor of Medicine (Diabetes), University of Wales,
Swansea & Honorary Consultant Physician, Swansea NHS
Trust, Singleton Hospital, Swansea, UK
Janesh K. Gupta MSC MD FRCOG
Clinical Senior Lecturer/Honorary Consultant in
Obstetrics and Gynaecology, University of Birmingham,
Birmingham Women’s Hospital, Birmingham, UK
Core Clinical Cases series edited by
Janesh K. Gupta MSc MD FRCOG

Clinical Senior Lecturer/ Honorary Consultant in
Obstetrics and Gynaecology, University of Birmingham,
Birmingham Women’s Hospital, Birmingham, UK
Hodder Arnold
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Contents
List of contributors vii
Series preface ix
Preface xi
Abbreviations xiii
Chapter 1 Diabetes 1
Steve Bain
Diagnosis 2
Glucose control for patients with diabetes mellitus 10
Diabetic small vessel complications 19
Diabetic large vessel complications 27
Diabetes emergencies 34
Chapter 2 Endocrinology 43
Andrew Levy
Hyperthyroidism 44
Addison’s disease (autoimmune adrenal failure) 49
Cushing’s disease 54
Acromegaly 59
Chapter 3 Rheumatology 63
Mark Pugh
Polyarthritis 64
Monoarthritis 71
Systemic rheumatological illnesses 78
Back pain 85
Chapter 4 Renal medicine 91

Indranil Dasgupta
Renal case studies 92
Renal emergencies 103
Chapter 5 Cardiology 111

Nevianna Tomson and Neeraj Prasad
vi Contents
Chapter 6 Care of elderly people 133

Peter Wallis
Falls 134
Immobility 145
Acute confusional states 156
Incontinence 165
Chapter 7 Respiratory medicine 173

Malcolm Shepherd and Neil C. Thomson
Dyspnoea 174
Pleuritic chest pain 183
Haemoptysis 193
Chapter 8 Gastroenterology 203

C. S. Probert
Gastroenterological emergencies 204
Pancreatitis 212
Inflammatory bowel disease 219
Peptic ulcer disease 226
Cirrhosis 233
Constipation 240
Hepatitis 247
Irritable bowel syndrome 253
Coeliac disease 260
Chapter 9 General surgery 267

Matthew Clark and Steven Thrush
Hernias 269
Gallstones 276
Appendicitis 284
Colon and rectal cancer 292
Surgical emergencies 300
Vascular: aortic aneurysm 304
Peripheral vascular disease 311
Vascular: carotid 316
Venous disease 319
Breast 322
Index 329
List of contributors
Matthew Clark BHB MBChB MD FRACS, General Surgeon and Clinical Associate Professor of
Surgery, University of Auckland, Middlemore Hospital, Auckland, NZ
Indranil Dasgupta MBBS MD DM FRCP, Consultant Nephrologist and Honorary Senior Lecturer,
Birmingham Heartlands Hospital, Birmingham, UK
Andrew Levy PhD FRCP, Reader in Medicine, Bristol University, and Honorary Consultant
Physician, Bristol Royal Infirmary, Bristol, UK
C. S. Probert MD ILTM FRCP, Consultant and Reader in Gastroenterology, University of Bristol,

Department of Clinical Science at South Bristol, Bristol Royal Infirmary, Bristol, UK
Neeraj Prasad MD FRCP, Consultant Cardiologist, Hereford County Hospital, Hereford, UK
Mark Pugh DTM DCH MD FRCPI, Consultant Rheumatologist and Clinical Tutor, Department of
Rheumatology, St Mary’s Hospital, Newport, Isle of Wight, UK
Malcolm Shepherd MBChB MRCP PhD, Balmforth Intermediate Clinical Scientist Research
Fellow, University of Glasgow, Glasgow, UK
Neil C. Thomson MBChB MD FRCP, Professor of Respiratory Medicine, University of Glasgow,

Glasgow, UK
Steven Thrush FRCS (Gen Surg), Consultant General Surgeon, Worcester Royal Hospital,
Worcester, UK
Nevianna Tomson MBChB MRCP, Specialist Registrar in Dermatology, Addenbrookes’ Hospital,

Cambridge, UK
Peter Wallis BSc MBBS FRCP, Consultant Geriatrician and Honorary Senior Clinical Lecturer,
University of Birmingham, Department of Elderly Medicine, Birmingham Heartlands
Hospital, Birmingham, UK
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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 time period as the 1918
influenza pandemic, and the two outbreaks have been linked ever since in the medical
literature. Some confused it with the epidemic of Spanish flu at that time whereas others
blamed weapons used in World War I.
Encephalitis lethargica was dramatized by the film Awakenings (book written by Oliver
Sacks who is an eminent neurologist from New York), 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 1916–27 epidemic, only sporadic cases have been described. Pathological studies
have revealed 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 (MRI) of the brain was normal in 60 per cent but showed inflammatory changes
localized to the deep grey matter in 40 per cent of patients.
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 1916–27 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 β-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 most 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 mystery of EL has been solved 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 are aetiologically related to rheumatic fever.
x Series preface
With this example of a truly fascinating history lesson, we hope that 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 all the Core Clinical Cases series, which will make you systematically explore clinical
problems through the clinical history of presentation, followed by examination and the
performance of appropriate investigations. Never break that rule.
Janesh Gupta
2006
Preface
Why core clinical cases?
In undergraduate medical education there is a trend towards the development of ‘core’

curricula. The aim is to facilitate the teaching of essential and relevant knowledge, skills
and attitudes. This contrasts with traditional medical school courses, where the emphasis
was on detailed factual knowledge, often with little obvious clinical relevance. In addition,
students’ learning is now commonly examined using objective structured clinical
examinations (OSCEs) which again assess the practical use of knowledge, rather than the
regurgitation of ‘small-print’.
Core cases in Medicine and Surgery cannot be an exhaustive list of all of the cases which
could be regarded as ‘core’, largely due to the massive scope of these specialties. However,
the volumes do present examples which can be used to train the reader in a realistic way
of approaching medical and surgical problems. This should help develop a learning strategy
for fifth year medical students to prepare for final examinations, as well as providing useful
revision for pre-registration house doctors taking on a new area.
Why a problem-solving approach?
In practice, patients present with clinical problems, which are explored through history,
examination and investigation progressively leading from a differential to a definitive
diagnosis. Traditionally, textbooks present the subject matter according to a
pathophysiological classification which does not help solve real-life clinical scenarios. We
have, therefore, based this book on a problem-solving approach. This inculcates the
capacity for critical thinking and should help readers to analyse the basis of clinical
problems. Of course we accept that the divisions within medicine and surgery are arbitrary,
but the areas covered by the specialties are so huge that chapter headings give a steer as
to which system will be involved. However, the reader should remember to include other
systems in their differential diagnosis, akin to the real life situation where a patient is
referred to a neurology clinic with fits but turns out to have a cardiovascular cause for their
symptoms.
How will this book inspire problem-solving traits?
The short case scenarios presented in these books are based on common clinical cases
which readers are likely to encounter in undergraduate medicine and surgery. These are
grouped according to the various subspecialties within medicine and surgery. Groups
include varying numbers of cases, each of which begins with a statement of the patient’s
complaint followed by a short description of the patient’s problem. For each case, using a
question and short answer format, the reader is taken through a problem-solving exercise.
xii Preface
There are two types of problem-solving cases in this book: one type deals with the
development of a diagnostic and therapeutic strategy; whilst the other deals with the
development of a counselling strategy. ‘Core’ information about the subject matter relevant
to the patient’s problem is also summarized, as this information is helpful for answering
the questions. The format of the book enables the cases to be used for learning as well as
for self-assessment.
In the cases that deal with diagnostic and therapeutic strategies, the reader is questioned
about the interpretation of the relevant clinical features presented, so as to compile an
array of likely differential diagnoses. They may then be asked to identify specific pieces of
information in the history and to select an appropriate clinical examination which will
narrow down the differential list to the most likely diagnosis. This emphasis is important
because, in clinical practice, history and examination result in a correct diagnosis in
80–90% of cases. Following this, readers are asked to suggest investigations which would
be required to confirm or refute the diagnosis. Once a diagnosis has been reached, readers
develop a treatment plan. In general terms, this should first consider conservative non-
invasive options (e.g. the important option of doing nothing), followed by medical and
surgical options.
In clinical practice, any therapeutic strategy has to be conveyed to patients in a manner

that they can understand. Therefore we have included problems that will challenge the
reader to develop a counselling strategy. These counselling cases will help and encourage
readers to communicate confidently with patients. This generic learning strategy is
followed throughout the book with the aim of reinforcing the skills required to master the
problem-solving approach.
Abbreviations
5-ASA 5-acetylsalicylic acid BAL bronchoalveolar lavage
AAA abdominal aortic aneurysm BLS basic life support
A&E accident and emergency BMI body mass index
ABGs arterial blood gases BP blood pressure
ABPIs ankle brachial pressure indices BPH benign prostatic hyperplasia
ACE angiotensin-converting enzyme BTS British Thoracic Society
ACR albumin:creatinine ratio CAPD continuous ambulatory
peritoneal dialysis
ACTH adrenocorticotrophic hormone
CCU coronary care unit
AF atrial fibrillation
CFA cryptogenic fibrosing alveolitis
Af atrial flutter
CHD coronary heart disease
ALI acute limb ischaemia
CPK creatine phosphokinase
ALT alanine aminotransferase
CK creatine kinase
ALP alkaline phosphatase
CK-MB isoenzyme of CK released
AMR acute mitral regurgitation
following myocardial cell
ANA antinuclear antibody damage
ANCA anti-neutrophil cytoplasmic CKD chronic kidney disease
antigen
CMV cytomegalovirus
APD automated peritoneal dialysis
CNS central nervous system
ARBs angiotensin II receptor blockers
COPD chronic obstructive pulmonary
AR aortic regurgitation disease
ARF acute renal failure CPAP continuous positive airway
pressure
ASD atrial septal defect
CPR cardiopulmonary resuscitation
AST aspartate aminotransferase
CRF chronic renal failure
ATLS advanced trauma life support
CRP C-reactive protein
ATN acute tubular necrosis
CSF cerebrospinal fluid
AV atrioventricular
CT computed tomography
xiv Abbreviations
CTPA CT pulmonary angiogram FFP fresh frozen plasma

CTS carpal tunnel syndrome FNA fine-needle aspiration
CVD cardiovascular disease FNAB fine-needle aspiration biopsy
CVP central venous pressure FSGS focal segmental
glomerulosclerosis
CVVH continuous veno-venous
haemofiltration FSH follicle-stimulating hormone
DC direct current fT4 free thyroxine
DEXA dual energy X-ray FVC forced vital capacity
absorptiometry
GBM glomerular basement
DIC disseminated intravascular membrane
coagulation
GCS Glasgow Coma Score
DKA diabetic ketoacidosis
GFR glomerular filtration rate
DMARDs disease-modifying anti-
GH growth hormone
rheumatoid drugs
GHRH GH-releasing hormone
DOT directly observed therapy
GI gastrointestinal
DRE digital rectal examination
GTN glyceryl trinitrate
DSA digital subtraction angiography
HAS human albumin solution
dsDNA double-stranded DNA
Hb haemoglobin
DVLA Driver and Vehicle Licensing
Agency HbA1c glycated haemoglobin
DVT deep venous (or vein) thrombosis HBGM home blood glucose monitoring
EAA extrinsic allergic alveolitis HDL high-density lipoprotein
ECG electrocardiogram HIV human immunodeficiency
virus
ENA extractable nuclear antigen
HLA human leukocyte antigen
ENT ear, nose and throat
HNPCC hereditary non-polyposis
ERCP endoscopic retrograde
colorectal cancer
cholangiopancreatography
HONK hyperosmolar, non-ketotic
ESR erythrocyte sedimentation rate
pre-coma or coma
ESRF end-stage renal failure
HPLC high-performance liquid
ET endotracheal chromatography
FBC full blood count HPOA hypertrophic pulmonary
osteoarthropathy
FEV1 forced expiratory volume in 1
second HR heart rate
Abbreviations xv
HRCT high-resolution computed MRI magnetic resonance imaging

tomography
MRSA methicillin-resistant
IBD inflammatory bowel disease Staphylococcus aureus
IBS irritable bowel syndrome MST morphine sulphate tablets
IC intermittent claudication MSU midstream specimen of urine
ICU intensive care unit MV mitral valve
IFG impaired fasting glycaemia NASH non-alcoholic steatohepatitis
Ig immunoglobulin NYHA New York Heart Association
IGF-I insulin-like growth factor I NSAIDs non-steroidal anti-inflammatory
drugs
IGT impaired glucose tolerance
OGTT oral glucose tolerance test
IHD ischaemic heart disease
PCK polycystic kidney disease
INR international normalized ratio
PE pulmonary embolus
ITU intensive therapy unit
PEF peak expiratory flow
LV left ventricular
PEFR peak expiratory flow rate
LVH left ventricular hypertrophy
PPI proton pump inhibitor
JVP jugular venous pressure
PR pulmonary regurgitation
LBBB left bundle-branch block
PS pulmonary stenosis
LFTs liver function tests
PSA prostate-specific antigen
LH luteinizing hormone
PTE pulmonary thromboembolism
LMW low molecular weight
PTH parathyroid hormone
MAOI monoamine oxidase inhibitor
PTP pre-test probability
MDR multidrug-resistant
PV plasma viscosity
MEN-1 multiple endocrine neoplasia
type 1 PVD peripheral vascular disease
MI myocardial infarction QCT qualitative computed
tomography
MMSE Mini-Mental State
Examination RAS renal arterial stenosis
MR mitral regurgitation RAST radioallergosorbent test
MRA magnetic resonance RBBB right bundle-branch block
angiography
RBC red blood cell
MRCP magnetic resonance
RF rheumatoid factor
cholangiopancreatography
xvi Abbreviations
RRT renal replacement therapy TSH thyroid-stimulating hormone
rtPA recombinant tissue plasminogen TEDS thromboembolic deterrent

activator stockings
RV right ventricular TTP thrombotic thrombocytopenic

purpura
RVH right ventricular hypertrophy
TURP transurethral resection of the
SBO small bowel obstruction
prostate
SBP spontaneous bacterial peritonitis
U&Es urea and electrolytes
SIADH syndrome of inappropriate
UKPDS UK Prospective Diabetes
antidiuretic hormone secretion
Study
SLE systemic lupus erythematosus
UMN upper motor neuron
SU sulphonylurea
UTI urinary tract infection
SVT supraventricular fibrillation
VA visual acuity
T4 thyroxine
VF ventricular fibrillation
TB tuberculosis
VSD ventricular septal defect
TC total cholesterol
VT ventricular tachycardia
TIA transient ischaemic attack
WBC white blood cell
TNF tumour necrosis factor
WCC white blood cell count
TR tricuspid regurgitation
WHO World Health Organization
TRUS transrectal ultrasonography
1Diabetes
Steve Bain
2 Diabetes
DIAGNOSIS
? Questions for each of the clinical case scenarios given

Q1: What specific questions would you ask the patient?
Q2: What investigations would you request to confirm a diagnosis?
Q3: What examination would you perform?
Q4: What would be the initial management?
Q5: What are the long-term sequelae?
Q6: What issues need to be addressed apart from blood glucose control?
Clinical cases
CASE 1.1 – A 73-year-old man with glycosuria and a finger-prick glucose of
11.4 mmol/L.
A 73-year-old man is found to have glycosuria on urine testing as part of a new patient assessment. A random finger-prick
test by the practice nurse using a modern, calibrated, glucose meter gives a level of 11.4 mmol/L. Arrangements are made
for a repeat blood test after an overnight fast; this plasma glucose level is analysed by the local hospital clinical chemistry
department and is reported at 6.7 mmol/L.
CASE 1.2 – A 57-year-old woman with lethargy and thrush and a fasting plasma
glucose of 8.2 mmol/L.
A 57-year-old woman presents to the surgery with lethargy. She has a long history of recurrent episodes of vaginal
irritation, which had been formally diagnosed as candidal thrush on one occasion. Treatment with clotrimazole leads to a
short amelioration of symptoms. A fasting plasma glucose level has been reported by the laboratory to be 8.2 mmol/L.
CASE 1.3 – A 21-year-old woman with a random finger-prick glucose of

18.9 mmol/L and urinary ketones.
A 21-year-old woman who has always been fit and well visits you shortly after her honeymoon. She has been profoundly
thirsty and noticing blurring of her vision. A finger-prick test in the surgery shows a blood glucose level of 18.9 mmol/L and
a fresh urine specimen has both glycosuria and heavy ketones (+++)
OSCE Counselling Cases

OSCE COUNSELLING CASE 1.1 – ‘Will I always have diabetes?’
A 53-year-old man is diagnosed with type 2 diabetes mellitus. He is treated with diet and subsequently oral agents. A
couple of years after diagnosis, he begins to take his diet more seriously and takes up regular exercise. He loses weight and
his glucose levels fall to such an extent that he is experiencing frequent hypoglycaemia. He is keen to reduce his
medication and wants to know if the diabetes is disappearing.
Diagnosis 3
OSCE COUNSELLING CASE 1.2 – ‘Does having diabetes affect my driving licence?’
A 48-year-old man is admitted to hospital with newly diagnosed diabetes. He is discharged on twice-daily insulin and after
6 weeks has established reasonable diabetic control with no hypoglycaemia. He has previously driven heavy goods vehicles
and is keen to return to work. He asks your advice about driving.
Key concepts
In order to work through the core clinical cases in this chapter, you will need to understand the following key concepts.
Diagnostic criteria for type 2 diabetes published by the World Health Organization and recommended by
Diabetes UK (2000)
Diagnostic tests should use plasma glucose measurements, from a venous sample and performed in an accredited
laboratory. Diagnosis should never be made on the basis of glycosuria or stick testing of a finger-prick blood glucose alone
(although these may be useful for screening).
If symptoms are present (i.e. polyuria, polydipsia and unexplained weight loss), the diagnosis can be made on the basis of a
single:
random plasma glucose ≥ 11.1 mmol/L
fasting plasma glucose ≥ 7.0 mmol/L
If symptoms are not present, two abnormal results (as above) on separate days are needed.
A fasting plasma glucose of 6.1–6.9 mmol/L is termed ‘impaired fasting glycaemia’ (IFG) and should be followed up by a
formal glucose tolerance test to exclude diabetes.
‘Impaired glucose tolerance’ (IGT) is defined by a formal glucose tolerance test as a 2-hour plasma glucose of 7.8–
11.0 mmol/L. This should lead to assessment of vascular risk factors and yearly screening of fasting plasma glucose.
4 Diabetes
Answers
CASE 1.1 – A 73-year-old man with glycosuria and a finger-prick glucose of
11.4 mmol/L.
A
A1
The detection of glycosuria has led to two tests to investigate the possibility of diabetes. The random glucose is elevated
(≥ 11.1 mmol/L) but, as a single test, is diagnostic only when it satisfies two criteria: it must be a venous sample (not
finger prick), analysed in an accredited laboratory, and it must be in association with symptoms of hyperglycaemia. So the
patient should be quizzed about typical symptoms, which will include lethargy, weight changes (gain or loss is possible),
polydipsia, polyuria, visual disturbance and infections (e.g. thrush, balanitis, boils). Even in the presence of symptoms, a
diagnosis of diabetes cannot be made because this has not been confirmed by the fasting plasma glucose, which is
< 7.0 mmol/L.
A2
This patient has IFG because his fasting plasma glucose is between 6.1 and 6.9 mmol/L. The guidelines suggest that IFG
should be followed up by a formal oral glucose tolerance test (OGTT). This may confirm a diagnosis of: IFG, if the 2-h
glucose is < 7.8 mmol/L; IGT, if the 2-h level is 7.8–11.0 mmol/L; or diabetes, if the 2-h glucose ≥ 11.1 mmol/L.
A3
Given the provisional diagnosis of IFG, there should be no evidence of diabetes-specific small vessel complications
(retinopathy, neuropathy, nephropathy); however, large vessel complications are possible. The cardiovascular system should
be examined for evidence of large vessel disease (carotid auscultation, palpation of peripheral pulses).
A4
Assuming that diabetes is not subsequently diagnosed by an OGTT, the patient would receive general health-care advice
about diet and exercise. Patients should be advised on an appropriate diet for treatment of diabetes (i.e. high carbohydrate,
high fibre, low saturated fat, low refined carbohydrate) with weight reduction if appropriate. A target body mass index
(BMI) of 25 kg/m2 is generally quoted. Recommended levels of exercise are regular moderate physical activity for sedentary
individuals and 30 min on 5 days a week for those who already take some moderate activity. Patients with IGT would be
followed annually by means of a fasting plasma glucose level.
Diagnosis 5
A5
Neither IFG nor IGT imparts any risk of specific small vessel complications and glycosuria related to a low renal threshold
for glucose is a benign condition. However, a diagnosis of IGT increases the future risk of type 2 diabetes, and is associated
with significant cardiovascular risk (in some studies, equivalent to the diagnosis of diabetes itself). It is assumed that IFG
carries similar prognoses.
A6
Cardiovascular risk factors need to be addressed, specifically smoking, lipid levels, blood pressure, exercise and obesity.
Aspirin may be considered.
CASE 1.2 – A 57-year-old woman with lethargy and thrush and a fasting plasma
glucose of 8.2 mmol/L.
A
A1
In this case, the presence of symptoms (lethargy, recurrent thrush) and the elevated fasting plasma glucose
(≥ 7.0 mmol/L) are sufficient to make the diagnosis of diabetes which, given her age, is almost certain to be type 2. She
should be questioned for other symptoms of hyperglycaemia (polyuria, polydipsia, visual disturbance, weight change) as
well as symptoms relating to small vessel disease (tingling, burning of the feet) and large vessel disease (angina,
claudication, etc.). A family history should be elicited and also a drug history to exclude the use of diabetogenic drugs (such
as steroids and thiazide diuretics).
A2
The diagnosis is already confirmed and additional tests are not necessary. Most clinicians would request a measure of long-
term glycaemic control (such as glycated haemoglobin [HbA1c]) as a baseline for future comparison.
A3
The UKPDS (UK Prospective Diabetes Study) showed that 40 per cent of patients with type 2 diabetes have evidence of
complications at diagnosis; examination should, therefore, focus on small and large vessel diabetic complications. For small
6 Diabetes
vessel complications, this would involve examination of the ocular fundi through dilated pupils (or arrangement for this to
be performed via a formal screening programme), and examination of the feet for evidence of peripheral neuropathy, in
addition to their general condition and the presence of pulses. There should also be a thorough examination of the
cardiovascular system. The patient should be weighed and a BMI calculated (weight (kg)/[height (m)]2).
A4
Most patients with type 2 diabetes are given a period of non-pharmacological management. Dietary advice, preferably from
a state-registered dietitian, should promote a diet high in complex carbohydrates but low in fat and refined sugars. If the
patient is overweight (BMI > 27 kg/m2) calorific reduction should also be advised. The benefits of regular exercise should
be stressed where appropriate. The patient should be taught how to monitor the impact of these changes by testing either
urine or blood (finger-prick testing).
These conservative measures are usually continued for at least 3 months unless the patient becomes more symptomatic, in
which case oral medication should be started.
A5
The patient is at risk of both small vessel and large vessel disease. Regular screening (at least yearly) should be performed
for diabetic retinopathy, diabetic neuropathy and diabetic nephropathy. Blood pressure (BP) and lipids should be monitored
and treated if necessary (below). All patients should be considered for aspirin prophylaxis.
A6
Other cardiovascular risk factors include:
Smoking: advise complete cessation.
Lipid levels: in the UK, use of statins for primary prevention of coronary heart disease (CHD) should be initiated when
the 10-year CHD risk is > 15 per cent. This figure can be calculated using the Framingham equation, which takes into
account age, sex, BP, lipids and ECG changes of left ventricular hypertrophy (LVH).
BP: treat initially with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker when
> 140/80 mmHg.
Diagnosis 7
CASE 1.3 – A 21-year-old woman with a random finger-prick glucose of

18.9 mmol/L and urinary ketones (+++).
A
A1
In this case, the diagnosis is type 1 (insulin-dependent) diabetes until proved otherwise.
This is based on the presence of ketones in the urine. Answers to further questions will probably support this view but
should not dissuade you from it. One might expect there to have been a short duration of symptoms (days to weeks), such
as profound weight loss, polyuria, nocturia, lethargy and recurrent infection.
In the absence of ketonuria, especially in an obese Asian individual, there is the possibility of early onset type 2 diabetes,
although this is by no means the ‘epidemic’ suggested by newspapers (and some medical journals). A strong family history
of early onset type 2 diabetes (affecting siblings, parents and grandparents) may also point to one of the rare autosomal
dominant forms of diabetes, but again ketonuria more or less excludes this.
A2
No laboratory confirmation is necessary.
Blood should be taken for a laboratory plasma glucose but this must not delay initial treatment. A baseline level of
glycaemic control would usually be requested (HbA1c or glycated haemoglobin) and a screen for associated autoimmune
disease (especially thyroid function) may be checked. Autoantibodies (e.g. islet cell, anti-insulin and antibodies to glutamate
decarboxylase) are negative in 20–30 per cent of newly diagnosed cases and so are of little clinical use (they will also take
some time to be reported). Insulin levels, likewise, are of little help and are not performed routinely.
A3
In a typical case of type 1 diabetes, there will be no evidence of diabetic complications at diagnosis because the duration of
hyperglycaemia will have been short-lived. Assessment should focus on the conscious level and circulatory state of the
patient because she could easily be acidotic, despite the relatively modest level of hyperglycaemia.
A4
The patient needs to be treated with insulin and so should be in a setting where the necessary expertise is available
(usually a hospital). If the patient is fit insulin can be started without the need for admission. Patients will need to be
taught how to monitor blood glucose using finger-prick tests and to understand the concepts of hypo- and hyperglycaemia.
8 Diabetes
They will also need to be shown how to test urine for ketones and understand the significance of these. Dietary advice will
be needed and appropriate targets for blood glucose levels agreed. Frequent contact over the early days and weeks after
diagnosis will be essential, ideally with an experienced diabetes nurse specialist.
A5
By virtue of her younger age at onset, this patient is at particular risk of the small vessel complications of diabetes,
specifically diabetic retinopathy, diabetic neuropathy and diabetic nephropathy. The minority who go on to develop diabetic
nephropathy (which usually manifests clinically after 15–25 years of disease) are prone to premature cardiovascular
disease, as well as being more susceptible to the other small vessel complications.
A6
The risk of specific diabetic complications and large vessel disease are issues that can be dealt with over the following
months and years. Of a higher priority are matters that may have an immediate impact. The first of these is hypoglycaemia,
which can occur from the moment that insulin injections are commenced. Patients need to be able to recognize the
symptoms of ‘hypos’ and take appropriate action (see Case 1.15 and OSCE Counselling Case 1.10). They should also be
aware that rapid lowering of blood glucose level can induce these symptoms, even when the blood glucose levels are
within the ‘normal’ range. This patient should also be given counselling about future pregnancy. Exemplary diabetic control
is necessary in the peri-conception period to reduce the risk of fetal abnormality.
Diagnosis 9
OSCE Counselling Cases – Answers

OSCE COUNSELLING CASE 1.1 – ‘Will I always have diabetes?’
The answer is unfortunately ‘yes’. This is certainly the case as far as medical and insurance matters are concerned. However,
by strict adherence to diet and regular exercise, it may be possible to reduce, or even eliminate, the need for medication.
This applies to both oral agents and insulin in patients with type 2 diabetes. In the case presented, medication should be
decreased or withheld so as to reduce the risk of hypoglycaemia.
Glucose levels tend to rise with age, and so patients with type 2 diabetes who are on a diet will ultimately need oral
medication (often labelled ‘diet failures’) and those on tablets may well need to go onto insulin.
People with type 1 diabetes may go through a period in the weeks to months after diagnosis where insulin can be
withheld. This is labelled the ‘honeymoon period’ and is thought to reflect the removal of the influence of hyperglycaemia,
which further depresses β-cell function. The continued (autoimmune) β-cell destruction ultimately means that insulin will
be required.
The prospect for a cure of diabetes is some way off in type 2 diabetes, but may be possible for type 1. Recent advances in
islet cell transplantation have allowed patients to become independent of insulin for more than 2 years. Unfortunately
problems surrounding islet availability/preparation and tissue rejection mean that this remains a research procedure.
OSCE COUNSELLING CASE 1.2 – ‘Does having diabetes affect my driving licence?’
The answer in this case is ‘yes’. The Driver and Vehicle Licensing Agency (DVLA) issue regular guidance on the medical
standards of fitness to drive. Licences are split into two groups (groups 1 and 2) with group 2 including heavy goods
vehicles (HGVs) and buses (passenger-carrying vehicles or PCVs). This patient should be advised to notify the DVLA that he
is taking insulin and that, while he does so, he is barred in law from driving HGVs. If the use of insulin is temporary he may
reapply for a licence when he has been transferred to another treatment.
Regarding his group 1 (motor car and motor cycle) licence, he must notify the DVLA but he can retain his licence so long as
he can recognize the warning symptoms of hypoglycaemia and is not experiencing disabling hypos. He should also advise
his insurance company of his change in health status.
Note that regulations change and so readers are advised to avail themselves of the most recent DVLA guidance.
NOTES ABOUT GROUP 1 ENTITLEMENT (MOTOR CARS AND MOTOR CYCLES) IN THE UK
Patients with type 2 diabetes managed on diet alone need not notify the DVLA unless they develop relevant
complications (e.g. retinopathy affecting visual acuity or visual fields)
Patients with type 2 diabetes treated with oral hypoglycaemic medication should notify the DVLA but will be allowed
to retain their licence until the age of 70 years, unless complications cause disability (as above).
Patients on insulin should notify the DVLA and must be able to recognize the warning symptoms of hypoglycaemia.
There are the same provisos regarding visual complications. Licences are granted for 1-, 2- or 3-year periods.
10 Diabetes
GLUCOSE CONTROL FOR PATIENTS WITH DIABETES MELLITUS
Q1: What are the treatment options?

Q2: What factors influence the choice of therapy?
Q3: What would be the preferred choice of treatment?
Q4: How would the impact of treatment be assessed?
Clinical cases
CASE 1.4 – A 72-year-old man with newly diagnosed type 2 diabetes.
A 72-year-old man has recently been diagnosed as having type 2 diabetes. He is mildly symptomatic with lethargy, thirst
and polyuria. A random blood glucose level is 13 mmol/L and dipstick urine testing revealed +++ glucose but no ketones.
He is a known hypertensive, taking bendrofluazide 5 mg once daily and his weight is stable at 94 kg (BMI 32 kg/m2). On
examination, there is no evidence of large or small vessel complications.
CASE 1.5 – An 84-year-old woman with type 2 diabetes has been treated with
gliclazide for 4 years.
A fit 84-year-old women with type 2 diabetes had been started on gliclazide after strict dietary adherence had failed to
control her symptoms. She now presents with persistently high glucose levels (home blood glucose monitoring or HBGM
12–15 mmol/L) and has an elevated HbA1c level (9.0 per cent) despite taking gliclazide, 160 mg in the morning, 80 mg in
the evening. She is symptomatic with lethargy, frequency and dysuria. Random fingerstick glucose is 15 mmol/L and urine
dipstick shows ++++ glucose, ++ albumin and + haematuria. BP is normal, weight is 67 kg (BMI 24 kg/m2) and she has
no evidence of retinopathy. There is early peripheral neuropathy and foot pulses are absent.
CASE 1.6 – A 57-year-old man treated with gliclazide 160 mg and metformin
500 mg three times daily, who has suboptimal glycaemic control.
A 57-year-old man with type 2 diabetes is currently treated with gliclazide 160 mg twice daily and metformin 500 mg
three times daily, but his glycaemic control is suboptimal. He reports blood glucose levels between 12 and 20 mmol/L) and
has an elevated HbA1c level (11.0 per cent). He claims good dietary adherence but is overweight (110 kg, BMI 33 kg/m2).
He denies any symptoms and has previously refused to consider insulin. He has normal VA but fundal photography shows
hard exudates encroaching on the left macula.

OSCE COUNSELLING CASE 1.3 – ‘I have been diagnosed as having maturity-onset
diabetes. Does this mean that I will never need go
on to injections?’
OSCE COUNSELLING CASE 1.4 – ‘I hate doing injections and painful blood tests for
my diabetes. Can I try an insulin pump instead?’
Key concepts
Glucose control for patients with diabetes mellitus
Type 2 diabetes is a condition caused by a combination of resistance to the action of circulating insulin (insulin resistance)
and β-cell failure (lack of insulin). The loss of β-cell function is a progressive disorder, which is not modified by commonly
used hypoglycaemic therapies (although more modern agents may have this benefit). This means that diet and then tablet
therapies will ultimately fail and, if the patient lives for long enough, rising blood glucose levels will eventually require
insulin therapy.
In the UK, the usual approach to glycaemic management is to start with modification of diet and exercise, often in the
hope of achieving weight reduction (obesity is associated with insulin resistance). Unless the patient is very symptomatic or
glucose levels are particularly high, this would be tried for at least 3 months. The target would be a HbA1c level < 7.5 per
cent, although some would advocate lower levels (7 per cent). If the target is not achieved oral medication is added.
Metformin is the commonly used agent, especially in obese individuals, because it does not promote weight gain and in
monotherapy should not render patients hypoglycaemic. Unfortunately, it has significant side effects, including anorexia,
nausea, abdominal discomfort, constipation and diarrhoea. These side effects are less pronounced if the dose is slowly
increased, so 500 mg once daily is commonly prescribed, building up to the maximum of 1 g three times a day with meals,
with weekly 500 mg dose increases.
If metformin is ineffective or not tolerated, sulphonylureas (SUs) are used. Gliclazide is the most commonly prescribed SU in
the UK, starting at 80 mg once daily with breakfast and increasing to a maximum of 320 mg, usually in two divided doses.
More modern preparations of this and other SUs allow for single daily dosing. As SUs act by increasing endogenous insulin
secretion, they can promote both hypoglycaemia and weight gain as side effects.
In patients who do not tolerate metformin, or in whom SUs are ineffective, a glitazone may be initiated. These agents
(currently rosiglitazone and pioglitazone are available in the UK) reduce insulin resistance and would, theoretically, be
better used early in the treatment of type 2 diabetes. However, the guidelines of the National Institute for Health and
Clinical Excellence (NICE) do not sanction this use; they are also contraindicated in combination with insulin. The use of all
three classes of agents is now licensed in the UK.
There are various ways of starting insulin in type 2 diabetes: it can be added to oral therapy, usually as a single dose of
long-acting insulin such as glargine or detemir, although the glitazone should always be stopped as a result of licensing
issues. This regimen has the advantages of simplicity but is ultimately doomed to fail with patients needing fast-acting
insulin to prevent post-prandial hyperglycaemia. This can either involve the addition of three pre-meal injections (a
12 Diabetes
standard basal bolus regimen) or a change to two pre-meal injections of premixed insulin. As far as reaching HbA1c targets
(6.5–7.5 per cent, the lower limit highlighting the risks of hypoglycaemia), the twice daily and add-on regimens are equally
(in)effective and one can argue there is less activity going straight to twice daily insulin when tablets fail. This also has the
advantage that patients can stop taking many tablets, although metformin is often continued to try to reduce the weight
gain that can be associated with insulin use.
Answers
CASE 1.4 – A 72-year-old man with newly diagnosed type 2 diabetes.
A1
The treatment options are wide and include the following:
Dietary review and manipulation
Exercise
Weight loss (achieved by diet and exercise although anti-obesity drugs may be considered)
Change of antihypertensive agent
Oral hypoglycaemic agents (metformin, an SU, acarbose, repaglinide, but not a thiazolidinedione or nateglinide
because these are not licensed for monotherapy in the UK)
Insulin.
A2
The choice of therapy is influenced by factors including the level of symptoms, the degree of hyperglycaemia, his weight
and the fact that there has been no weight loss, and his age. This patient is said to have type 2 diabetes and this fits with
his age, symptoms, obesity and hypertension. His symptoms are mild, glucose level is moderately elevated and there are no
ketones in the urine. He currently takes a high-dose thiazide diuretic, which, in some cases, can cause glucose intolerance.
A3
A reasonable course of action would be to advise on diet (see answer A4 to Case 1.1) with the aim of reducing daily
calorie intake and increasing exercise. The bendrofluazide could be stopped and replaced with an ACE inhibitor. Assuming
that he does not become more symptomatic, this regimen could be followed for 3 months at which point oral
hypoglycaemic agents may be considered. The first-line agent would be metformin, based on his obesity.
14 Diabetes
A4
The patient should be made aware of the symptoms of hyperglycaemia and make contact if these appear to worsen,
especially if weight loss is marked. The technical options to assess the glycaemic response are near patient (usually self-)
testing of urine or blood glucose and laboratory testing (HbA1c levels and fructosamine).
Home blood glucose monitoring is commonly taught to patients in this scenario, but critics argue that it is of little value
and very expensive (in the UK more NHS budget is spent on monitoring than on oral hypoglycaemic drugs). Unless a
patient or the clinician is going to manipulate therapy based only on the results of HBGM (and this is not the case here),
one can argue that it should not be routine practice. The same could also be said of urine glucose testing.
Glycated haemoglobin and fructosamine levels provide a long-term indication of glycaemic control (HbA1c 2–3 months,
fructosamine 2–3 weeks) and, if compared with a baseline value, will give a good indication as to whether conservative
measures are being effective. HbA1c also allows for targets to be set, typically aiming for a level of 6.5–7.5 per cent
(aligned with the Diabetes Control and Complications Trial [DCCT] assay).
Don’t forget that a change in blood pressure therapy means that BP monitoring will need to be performed on a monthly
basis and, if an ACE inhibitor is used, electrolytes will need to be checked beforehand and after 7–14 days of treatment.
CASE 1.5 – An 84-year-old woman with type 2 diabetes has been treated with
gliclazide for 4 years.
A1
The treatment options include:
Further dietary review and manipulation
Increase the dose of SU (gliclazide)
Add another oral hypoglycaemic agent (metformin, acarbose, thiazolidinedione, repaglinide, nateglinide)
Add or substitute insulin for gliclazide
Exclude urinary tract infection (UTI) or treat if this is confirmed.
A2
The choice of therapy is influenced by the natural history of her condition, her weight, her current therapy and her age. Type
2 diabetes is a progressive disease and so failure of diet and then oral monotherapy to control her symptoms should be
anticipated (and not attributed to failure on the part of the patient). Although a dietary assessment is reasonable (and
should be performed as part of the annual diabetes review), she has previously been strict and is not currently overweight.
In this setting, it is unlikely that dietary change will make a significant impact. Her current dose of gliclazide is not the
maximum recommended; however, the dose–response curve tends to be flattened at higher doses and so additional
therapy would usually be instituted. Given her age, tight glycaemic control is not a priority and symptomatic relief with low
risk of hypoglycaemia is the aim of treatment. Note that the possibility of diabetic foot complications does not influence
the treatment choices
Although hyperglycaemia causes lethargy and frequency, dysuria with proteinuria and haematuria on dipstick testing
suggest the possibility of a UTI (common in hyperglycaemia and a cause of worsened diabetic control). If confirmed by
urine culture a course of antibiotics would be indicated.
A3
Add a second oral agent to her current dose of gliclazide. Thiazolidinediones are currently licensed for use in this
combination only where metformin cannot be tolerated or is contraindicated. The use of repaglinide (an SU derivative) and
nateglinide (an insulin secretagogue) with an SU is not recommended. Acarbose is poorly tolerated as a result of
abdominal side effects (especially increased flatus) and so metformin would be the agent of choice. This should be started
at a low dose (500 mg once daily for 1 week) and then increased weekly according to the blood glucose response, to a
maximum of 3 g/day, so as to reduce the possibility of side effects.
A4
Given that the patient is already performing HBGM, it is not unreasonable for her to continue this practice and ask her to
increase the dose of metformin according to the glucose response. Fasting, pre-meal and pre-bed glucose testing is the
norm, with targets of < 10 mmol/L without hypoglycaemia being reasonable in this case. HbA1c testing could also be
performed after 3 months for comparison with the pre-treatment level. The patient should monitor for side effects (which
include any form of gastrointestinal disturbance) and reduce the metformin dose by 500 mg if these occur.
CASE 1.6 – A 57-year-old man treated with gliclazide 160 mg and metformin
500 mg three times daily, who has suboptimal glycaemic control.
A1
The treatment options include:
Further dietary review and manipulation
Increasing the dose of metformin
Adding another oral hypoglycaemic agent (thiazolidinedione or acarbose)
Replacing one of his current oral agents with another (repaglinide or nateglinide)
16 Diabetes
Insulin
Insulin and oral hypoglycaemic medication.
A2
The choice of therapy is influenced by the natural history of the condition, his current therapy, age and weight, and the
presence of retinopathy. The progressive nature of type 2 diabetes is such that all patients will end up on insulin if they
survive for long enough. Although he is not on maximal doses of metformin, further increases are unlikely to achieve
glycaemic targets. There is no evidence for greater efficacy of repaglinide or netaglinide over an SU in this setting, and the
addition of acarbose is likely to have only a small effect. Addition of a glitazone (triple therapy) is an alternative but is often
a disappointing combination in this type of scenario. So insulin becomes a leading option, especially given his young age
and the development of diabetic retinopathy. Clearly the patient is not keen to go on to insulin and the reasons for this
need to be explored, because many patients are pleasantly surprised at how painless insulin injections are (compared with
HBGM). A dietary assessment is reasonable because weight gain on insulin is a real possibility and one may consider the
combination of insulin with metformin.
A3
Suggest to the patient that he tries insulin for a period. This will allow him to see how simple the procedure can be and if,
like many patients, he feels better on insulin he will wish to stay on it. Twice daily insulin using fixed mixtures before
breakfast and evening meal is a simple regimen that may seem less daunting than basal bolus (where patients inject fast-
acting insulin before each meal and a night-time injection of long-acting insulin). Given the risk of weight gain, he should
continue on metformin but can cease taking his SU.
A4
Symptomatic improvement (he may recognize and admit to symptoms in retrospect, especially lethargy) and HBGM will
provide feedback on progress. He should also monitor his weight.

OSCE COUNSELLING CASE 1.3 – ‘I have been diagnosed as having maturity-onset
diabetes. Does this mean that I will never need go
on to injections?’
The short answer is ‘no’.
Maturity-onset diabetes is the old term for non-insulin-dependent diabetes, now called type 2 diabetes mellitus. The natural
history of this condition has been convincingly demonstrated and is one of progressive deterioration in blood glucose
control. This is felt to reflect progressive loss of β-cell function over time. Insulin resistance, the other contributing
metabolic abnormality, appears to deteriorate before the diagnosis of type 2 diabetes but then remains relatively fixed.
As a result of β-cell failure, dietary change is likely to have a limited and temporary impact, leading to the introduction of
oral hypoglycaemic agents. Ultimately these agents will fail and the patient may need insulin to achieve reasonable
glycaemic control. One can argue that, if an individual with type 2 diabetes lives for long enough, insulin is inevitable. This
can be used as a justification for early exposure to the use of insulin (handling injection devices, experiencing the injection)
so that, when insulin is needed, it is not delayed by unjustified fears.
The exception to this rule of progressive glycaemic deterioration may be patients who are obese at diagnosis and manage
to lose vast amounts of weight, thereby restoring insulin sensitivity. There are also preliminary data that thiazolidinediones
can slow the progression of β-cell dysfunction but these need to be confirmed.
LEARNING POINTS
Type 2 diabetes is the modern name for maturity-onset (non-insulin-dependent) diabetes.
The natural history of this condition is for blood glucose control to deteriorate over time, as a result of β-cell failure.
If survival is prolonged, insulin treatment will be needed in most cases of type 2 diabetes.
It is the treatment, not the patient, who has ‘failed’ and this should be expected and anticipated. Patients can be
introduced to the concept of insulin at an early stage and should not be ‘threatened’ with its introduction.
OSCE COUNSELLING CASE 1.4 – ‘I hate doing injections and painful blood tests for
my diabetes. Can I try an insulin pump instead?’
Insulin pumps (also known as continuous subcutaneous insulin injections) are now available in the UK but this is not a
good reason for using one because the amount of fingerstick testing is usually increased.
The use of an insulin pump involves the insertion of a cannula into the subcutaneous tissue, through which small amounts
of insulin are continuously delivered. In addition, bolus doses can be administered by the same equipment, to coincide with
meals. The pumps themselves are small devices (equivalent to a modern mobile phone) and can easily be carried in a
belt/holster.
The NICE has recently (2003) advised that pump therapy can be made available to people with type 1 diabetes where
multiple insulin dose therapy has failed to achieve good glycaemic control. Type 2 diabetes is not currently regarded as an
indication for pump use. Patients should be able to maintain ‘a high order of personal hygiene’ (in order to avoid catheter
site infection) and test fingerstick blood glucose four times a day. In addition, they should be capable of estimating
carbohydrate and calorie consumption, programming the pump and changing the cannula site every 2–3 days. It is
estimated that, in the UK, no more than 1 in 20 patients would satisfy these pre-conditions.
18 Diabetes
Although the NICE recommends that the NHS fund these devices, until now they have required self-financing and this has
been an important issue. The devices cost about £1000 each and consumables amount to £700–1000 per year.
LEARNING POINTS
Insulin pumps are available for therapy of type 1 diabetes in the UK.
They are indicated where control remains poor despite multiple insulin injection regimens.
Patients need to be highly motivated and technically competent.
Cost may also be an issue.

DIABETIC SMALL VESSEL COMPLICATIONS
Q1: What questions would you ask the patient and why?
Q2: What investigations would you request?
Q4: What are the differential diagnoses related to diabetes?
Clinical cases
CASE 1.7 – A 75-year-old man with long-standing type 2 diabetes complains of
difficulty in seeing the TV.
A 75-year-old man with diabetes of 15 years’ standing complains of difficulty in seeing the TV. There has been no pain or
redness affecting his eyes and he has not had headaches. His diabetic control is poor but stable.
CASE 1.8 – A 31-year-old man with type 1 diabetes has albuminuria on urine
dipstick testing.
A 31-year-old man with type 1 diabetes has joined your practice. He was diagnosed aged 12 years and, having attended
the clinic regularly as a child, defaulted from the adult clinic, attending only when he needed replacement equipment
(injection devices, etc.). He takes no other medication and has had no treatment for complications. BP: 160/80 mmHg;
dipstick urine testing: +++ glucose, ++ albumin, + blood, but no ketones; visual acuity (VA): 6/6 in both eyes.
CASE 1.9 – A 56-year-old man with newly diagnosed type 2 diabetes complains
of pins and needles in his feet.
A 56-year-old man is diagnosed as having type 2 diabetes by his local optometrist. He attends your practice and during
diabetic review complains of ‘pins and needles’ affecting both his feet and his right hand. The symptoms are worse at night
when he is in bed. Discomfort in his hand often disturbs his sleep. There is no discomfort in the feet during the day and
exercise tolerance has been unaffected.
20 Diabetes

OSCE COUNSELLING CASE 1.5 – ‘Do all people with diabetes end up on kidney
dialysis treatment?’
OSCE COUNSELLING CASE 1.6 – ‘My friend has diabetes and she says that all
people with diabetes should go to a chiropodist. Is
this true?’
Key concepts
Long-term complications of diabetes are traditionally divided into diabetes-specific, small vessel complications (meaning
that only patients with diabetes are at risk) and non-specific, large vessel complications (increased risk in diabetes but not
limited to that condition). The small vessel complications are:
Eye disease: diabetic retinopathy – the most common cause of blindness in the working population of the UK
Nerve disease: diabetic neuropathy – usually a progressive peripheral neuropathy that presents with tingling and
burning affecting the feet and progresses to complete sensory loss
Kidney disease: diabetic nephropathy – the most common cause of end-stage renal failure in western economies
There is, however, crossover between the small and large vessel complications, e.g. patients with diabetic nephropathy have
a greatly increased risk of ischaemic heart disease and most will succumb to this, rather than end-stage renal failure.
The diabetes annual review aims to detect diabetes complications at an early stage and institute therapy before there has
been irreversible damage (e.g. laser treatment for retinopathy to prevent loss of visual acuity).
Answers
CASE 1.7 – A 75-year-old man with long-standing type 2 diabetes complains of
difficulty in seeing the TV.
A
A1
Symptoms of cataract progression include halos around bright lights, such as car headlights. The symptoms are usually slow
in progression but patients may report abrupt changes. Maculopathy may give either a slow or a sudden loss of vision in
one eye whereas a bleed related to proliferative diabetic retinopathy classically causes sudden, painless, visual loss in one
eye. Note that patients may be unaware of the extent of loss of vision if the good eye compensates. Changes in vision
related to poor glycaemic control (usually enhanced long vision and difficulty reading) may affect both eyes and can be
variable over short periods. During periods of poor glycaemic control (e.g. at diagnosis) patients should be advised against
changing their lens prescription.
A2
In the vast majority of cases, the history and examination will be sufficient.
A3
Visual acuity should be tested, with correction (spectacles) if the patient normally uses these for distance vision. Pinhole
correction should be performed if the VA is 6/9 or less. Examination of the fundi through dilated pupils (1 per cent
tropicamide) is mandatory. This will allow detection of a cataract by examination of the red reflex and also detection of
retinal abnormalities by direct visualization, including those concerning diabetes and related medical disorders. Ideally,
binocular stereomicroscopy should be performed (usually in the setting of an ophthalmic clinic), which facilitates the
detection of macular oedema. Digital images may also be requested.
A4
The major possibilities related to his diabetes are:
Cataract
Diabetic retinopathy (more likely maculopathy than proliferative diabetic retinopathy)
Change in blood glucose levels leading to alteration in lens shape
Related retinal disorders such as central retinal vein and/or artery occlusion.
22 Diabetes
CASE 1.8 – A 31-year-old man with type 1 diabetes has albuminuria on urine
dipstick testing.
A
A1
He should be asked about symptoms of UTI (frequency, dysuria, nocturia, haematuria, etc.) Although his attendance at
clinic has been sporadic, he will have had urine testing previously, so he should be quizzed as to whether he had been told
about urinary abnormalities (especially albuminuria) before. Previous blood pressure assessments would also be of value
because this one-off reading may reflect anxiety-induced (white-coat) hypertension. A family history of hypertension and
ischaemic heart disease are also more common in patients at risk of diabetic nephropathy.
A2
A midstream urine specimen (MSU) should be sent for culture to exclude a UTI. If excluded then formal assessment of the
albumin excretion is needed; this can be by one of the following, depending on the expected compliance: 24-hour urine
collection for albumin; timed overnight urine collection for albumin excretion rate; first voided urine for albumin:creatinine
ratio (ACR). Blood should be sent for HbA1c to assess glycaemic control, lipids should be checked (total and high-density
lipoprotein [HDL]-cholesterol) and creatinine. Haematuria is not typical of diabetic nephropathy and so renal
ultrasonography should be arranged to exclude other causes of albuminuria (rare in this setting).
A3
People with type 1 diabetes and diabetic nephropathy are at high risk of other complications. The feet should be examined
for evidence of peripheral neuropathy and reduced circulation. Coexisting diabetic retinopathy is almost inevitable and so
arrangements for dilated fundoscopy should be made. Blood pressure should be repeated after a period of rest and then
follow-up arrangements for more BP checks over the next 2–3 months to establish whether there is a persistent elevation.
If diabetic nephropathy is confirmed a target systolic pressure of 125 mmHg is recommended.
A4
UTI
Diabetic nephropathy: the duration of disease (19 years) is typical and it is likely that his control has been poor (given
the poor clinic attendance). In addition to the albuminuria, he has raised BP, which is part of the syndrome.
CASE 1.9 – A 56-year-old man with newly diagnosed type 2 diabetes complains
of pins and needles in his feet.
A
A1
Peripheral neuropathy symptoms (to which burning dysthesia may be added) are of gradual onset, typically worse at rest
and in bed, when bedclothes can be particularly irritating. Autonomic neuropathy (rare) may also be present, with
symptoms including gustatory sweating (facial sweating after meals) and postural hypotension.
Carpal tunnel syndrome (CTS) is common at night, patients often being awoken with discomfort and typically shaking the
hand to relieve symptoms. Excessive use of the hands (e.g. painting) may also induce symptoms. It may be associated with
loss (or change) of sensation in the hand and symptoms can be referred to the whole forearm. Once again, a gradual onset
of symptoms would be expected and the other hand may also be affected.
Given the association of CTS with myxoedema, acromegaly, rheumatoid arthritis and osteoarthritis, symptoms of these
conditions may be elicited.
A2
Nerve conduction studies will confirm a diagnosis of both peripheral diabetic neuropathy and CTS. They are most useful in
the latter where surgical intervention can be considered when entrapment is confirmed. Bloods to exclude hypothyroidism
should also be requested.
A3
Examination of the feet for abnormal sensation, using monofilaments and vibration sensation as screening tools. Ulceration
(painless) should be excluded and skin care assessed. Peripheral pulses should be examined and may be ‘bounding’ in the
neuropathic foot.
In CTS there may be sensory loss over the palmar aspects of the first three-and-a-half fingers and wasting of the thenar
eminence. In advanced cases, there can be weakness of abduction, flexion and apposition of the thumb. Symptoms can be
worsened by various manoeuvres such as percussion of the carpal tunnel (Tinel’s sign), flexion of the wrist (Phalen’s sign)
and hyperextension of the wrist.
Given the association of CTS with myxoedema, acromegaly, rheumatoid arthritis and osteoarthritis, signs of these
conditions may be looked for.
24 Diabetes
A4
Peripheral diabetic neuropathy affecting the feet and possibly the right hand. Although recently diagnosed, the patient
has clearly had diabetes for some time to manifest retinal changes. Hence, other long-term complications of diabetes
may also be present.
CTS affecting the right hand.
A mononeuropathy affecting the right hand.
Vascular insufficiency is an UNLIKELY cause of symptoms given the absence of claudication.


OSCE COUNSELLING CASE 1.5 – ‘Do all people with diabetes end up on kidney
dialysis treatment?’
No.
There may appear to be a paradox in that diabetes is now the most common cause of end-stage renal failure in the
western world and renal dialysis as a result of diabetes is becoming more frequent. However, this relates to the massive
increase in the numbers of people diagnosed as having diabetes, and the vast majority will never need dialysis treatment.
Taking the example of type 1 diabetes, studies from the 1960s and 1970s show that only a minority (at most 40 per cent)
of patients will develop diabetic nephropathy, irrespective of their glycaemic control. This is likely to represent a genetic
predisposition to diabetic nephropathy, which means that most patients are protected from this complication (contrast with
diabetic retinopathy where all patients continue to be at risk). Continued improvements in BP, lipids and glucose control
will inevitably reduce this proportion.
In type 2 diabetes, the major risk associated with abnormal albumin excretion is cardiovascular disease, which tends to
cause premature death long before renal dialysis becomes a possibility. Although advances in the pharmacotherapy of BP
and lipids may reduce the premature heart deaths, they are also likely to preserve renal function so that this largely elderly
cohort will not end up on dialysis.
LEARNING POINTS
Diabetes is the most common cause of end-stage renal disease in the western world.
The number of people with diabetes going on to renal dialysis programmes is likely to increase as a result of the rise in
prevalence of diabetes.
Susceptibility to diabetic nephropathy is partly genetically determined with most patients protected from this
complication
With advances in BP, lipid and glucose management, the proportion of people with diabetes, especially type 1, needing
renal replacement therapy is likely to fall.
Diabetic nephropathy greatly increases the risk of other diabetic complications, including premature coronary heart
disease (CHD).
OSCE COUNSELLING CASE 1.6 – ‘My friend has diabetes and she says that all
people with diabetes should go to a chiropodist. Is
this true?’
No.
The level of resource directed towards diabetic foot care should be dictated by the individual needs. This has led to a risk
categorization with varying levels of input.
26 Diabetes
NORMAL FEET (LOW RISK)

All newly diagnosed patients should receive basic foot health advice and subsequently be reviewed on an annual basis. This
assessment can be carried out by a doctor, diabetes nurse specialist or practice nurse (with the appropriate level of
training). If, at any stage, the patient is found to be ‘at risk’ or to have active foot disease, then referral should be made as
follows:
AT RISK
Patients with reduced sensation, reduced pedal pulses or unable to perform nail chiropody (or have it provided by a
responsible carer) should be seen 3- to 6-monthly for review by a chiropodist. Foot care advice should be given and the
need for vascular assessment reviewed.
HIGH RISK
Patients with a risk factor for foot disease and either foot deformity or a previous ulcer should be seen 1- to 3-monthly by a
senior podiatrist. Specialist foot care treatment and advice should be given, as per the published guidelines. There should
be easy access to a shoe fitter, surgical appliances and, where necessary, a limb fitting centre.
ACTIVE FOOT DISEASE

Patients with active ulceration, cellulitis, osteomyelitis, a Charcot joint or foot discoloration should be seen urgently in a
multidisciplinary diabetic foot clinic. In addition, any patient who has had an ulcer for more than 6 weeks should be
referred for multidisciplinary assessment.
LEARNING POINTS
All people with diabetes need foot assessment and advice at diagnosis and at least yearly thereafter.
This can be performed by different health-care professionals, so long as they have been adequately trained.
The intensity of clinical input depends on the risk categorization of each individual case.
DIABETIC LARGE VESSEL COMPLICATIONS
Q1: Are further assessments required before the italicized finding provokes a drug intervention?
Q2: If drug therapy were indicated, which would be the most appropriate choice of agent?
Q3: What sort of follow-up is indicated?
Q4: What other issues need to be addressed as regards cardiovascular risk?
Clinical cases
CASE 1.10 – A 68-year-old man with type 2 diabetes and a total cholesterol of
5.6 mmol/L.
A 68-year-old man with type 2 diabetes has a new person check in primary care. He has no other significant medical
history apart from diabetes and he does not smoke. His BMI is 32 kg/m2 and he has no evidence of diabetic retinopathy or
foot complications. BP 170/96 mmHg and urinalysis shows glycosuria ++ but no protein. A random total cholesterol (TC) is
5.6 mmol/L and triglycerides 2.3 mmol/L. He takes metformin 1 g twice daily and has an HbA1c level of 7.5 per cent
(normal range < 5 per cent).
CASE 1.11 – A 76-year-old woman with type 2 diabetes and a stable blood
pressure of 166/70 mmHg.
A 76-year-old woman with type 2 diabetes is under regular review. She has a history of angina, which is well controlled,
and does not smoke. Her BMI is 28 kg/m2 and she has background diabetic retinopathy and absent foot pulses. BP 166/70
mmHg and urinalysis shows persistent + albuminuria in the absence of infection. BP recordings over the previous 6 months
have shown similar levels. She takes gliclazide 80 mg twice daily, and isosorbide mononitrate 60 mg, simvastatin 10 mg
and aspirin 75 mg once daily. A random TC is 4.8 mmol/L, triglycerides 2.3 mmol/L. and HbA1c 7.8 per cent (normal range
< 5 per cent).
CASE 1.12 – A 21-year-old woman with type 1 diabetes and microalbuminuria

(urinary albumin:creatinine ratio of 2.7).
A 21-year-old woman with type 1 diabetes of 15 years’ standing has an annual review of her diabetes. She injects insulin
using a basal bolus regimen and does not smoke. Her BMI is 22 kg/m2, BP 120/60 mmHg and she has good pedal pulses.
She has minimal background diabetic retinopathy and slightly diminished sensation in her feet. Random TC is 5.7 mmol/L,
triglycerides 1.1 mmol/L. and HbA1c 6.5 per cent (normal range < 5 per cent). Analysis of a random urine shows an ACR of
2.7 which is reported as ‘microalbuminuria’. Previously urinalysis had been negative for dipstick proteinuria.
28 Diabetes

OSCE COUNSELLING CASE 1.7 – ‘As someone with diabetes, should I be taking
aspirin?’
OSCE COUNSELLING CASE 1.8 – ‘Why is my blood pressure so difficult to control?’
Key concepts
People with diabetes get the same large vessel disease as those who don’t have diabetes, but they get it earlier and it is
more widespread
Cardiovascular disease: 75 per cent of people with type 2 diabetes will die as a result of ischaemic heart disease (IHD) and
some studies suggest that IGT carries a similar cardiovascular prognosis to overt type 2 diabetes. This implies that glucose
control is not the dominant issue, and is consistent with the limited impact of glycaemic control in the UKPDS. Contrast this
with the major impact of blood pressure and lipid control.
Peripheral vascular disease: diabetes is the most common cause of non-traumatic lower limb amputation in the UK.
Cerebrovascular disease: stroke is two to four times more common in diabetic cohorts.
Hence there is a focus on CHD prevention (both primary and secondary) in diabetes management with attention to lipids,
BP control (and to a lesser extent aspirin) and a sound evidence base. Microalbuminuria screening is also recommended in
this context (as a marker of early vascular disease) but the rationale for this is less convincing.
Answers
CASE 1.10 – A 68-year-old man with type 2 diabetes and a total cholesterol of
5.6 mmol/L.
Q1: Are further assessments required before the italicized finding provokes a
drug intervention?
A1
The total cholesterol (TC) warrants consideration in terms of primary prevention of cardiovascular disease. Issues are:
whether fasting lipids are required, the potential impact of diet and what level of cholesterol justifies drug treatment. The
guidelines are constantly changing in view of additional trial evidence.
Total cholesterol is not altered by recent food intake (unlike triglyerides) and so a fasting sample is not mandatory. Most
clinicians would, however, repeat the lipids so as to include an HDL-cholesterol. This allows for the assessment of the
patient’s 10-year CHD risk using the Framingham or similar calculation. Framingham includes age, sex, diabetes status,
smoking history, TC and HDL-cholesterol levels, and presence/absence of LVH on ECG. According to the Standing Medical
Advisory Committee in the UK, a CHD risk > 30 per cent is a justification for the use of drugs for primary prevention, so
long as the total cholesterol is > 5.0 mmol/L. (After results from the Heart Protection Study in 2002, the guidance about
statin treatment may be changed. This placebo-controlled study showed that, in cases at high risk of CHD (including people
with diabetes), use of statins produced benefit in patients with a TC > 3.5 mmol/L irrespective of their HDL-cholesterol. On
these grounds, this patient would be treated with a statin, irrespective of other CHD risk factors.)
For most patients, diet has little impact on TC levels, and this is borne out by the large statin trials, which show a reduction
of only 2–4 per cent in diet-treated patients.
Q2: If drug therapy were indicated, which would be the most appropriate choice
of agent?
A2
A statin, in a dose that provides a 25 per cent reduction in TC. In the case of simvastatin, 40 mg once daily taken in the
evening should be prescribed and, for other statins, a dose equivalent to this (e.g. 20 mg atorvastatin). There is currently no
evidence that fibrates or any of the older lipid-lowering drugs produce cardiovascular benefits in this case scenario.
A3
Liver function tests (LFTs) and creatine kinase (CK) should be checked before initiation of statin treatment, but are probably
not needed again unless the dose is increased. At the same time thyroid function tests could be requested, to exclude
underlying hypothyroidism, which can raise cholesterol levels. Patients should be aware of the risk of muscle pains, which
are rarely the result of myositis, and CK should be checked if they experience this symptom. Lipids should be repeated after
3 months of treatment and, if targets have been hit, checked on a yearly basis thereafter.
30 Diabetes
A4
One needs to give consideration to glycaemic control, smoking, BMI, BP and drug therapy, although not in that order. The
evidence that improving blood glucose control and reducing weight would have a major impact on CHD risk in this case is
weak. In contrast, BP control is crucial; however, one needs to know that the reading taken on this visit is representative
and not anxiety induced (so-called white coat hypertension). An ECG may be helpful, because evidence of LVH would imply
long-standing hypertension; however, if this were normal then repeated BP checks should be arranged. A minimum of
three recordings over a 3-month period would be appropriate with consideration of drug therapy if the level remains
> 140/80 mmHg. Once again, additional dietary measures are unlikely to have much impact. Finally the patient should take
aspirin 75 mg once daily unless there are known contraindications.
CASE 1.11 – A 76-year-old woman with type 2 diabetes and a stable blood
pressure of 166/70 mmHg.
drug intervention?
A1
This patient with diabetes, IHD and peripheral vascular disease has isolated systolic hypertension confirmed by multiple
assessments over time. The literature strongly supports reduction of her systolic pressure using drugs to a target of
140 mmHg. Further attention to weight, exercise and glycaemic control would be beneficial but they have minimal impact
on her BP. Apart from baseline urea and electrolytes (U&Es), no further investigations are required at this point.
of agent?
A2
The first-line antihypertensive agent in a person with diabetes and proteinuria should be an inhibitor of the
renin–angiotensin system. Although this would usually involve the use of an ACE inhibitor, there is increasing evidence to
support the use of angiotensin II receptor blockers (ARBs). Check that U&Es have been performed before initiation and
7–10 days thereafter. For a substantial proportion of people with diabetes monotherapy is not sufficient to achieve BP
targets and additional classes of BP medication will be needed. A typical second-line agent in this case would be a low-
dose diuretic.
A3
The effect of drug therapy may take 2 months to become apparent. An interim target BP of 160 mmHg is appropriate and,
if the patient feels well having achieved this, further increases in medication should be made aiming for systolic BP 140
mmHg. Once stabilized, BP can be checked at 3- to 6-month intervals. Patients on ACE inhibitors and ARBs should have
renal function and electrolytes checked at regular intervals (about 6 monthly) because renal function can deteriorate at any
time. Additional tests are required if the dose of ACE inhibitor/ARB is increased, additional medication is added or there is
intercurrent illness.
A4
Attention to glycaemic control, weight and exercise is justified but unlikely to have a significant impact on CHD risk. One
should review her other medications, increasing the simvastatin dose to 40 mg once daily (the dose on which most of the
evidence for this agent is based) and increase the dose of aspirin which should be 150 mg once daily, given her known
IHD.
CASE 1.12 – A 21-year-old woman with type 1 diabetes and microalbuminuria

(urinary albumin:creatinine ratio of 2.7).
drug intervention?
A1
Screening for microalbuminuria in patients with type 1 diabetes is commonly part of the diabetes annual review. It aims to
detect the easy stages of diabetic nephropathy, before the onset of dipstick-positive proteinuria (so-called
macroalbuminuria). Diabetic nephropathy is a clinical syndrome of persistent proteinuria, hypertension and declining renal
function. Patients with this complication have increased premature morbidity and mortality as a result of end-stage renal
failure, cardiovascular disease and other diabetes complications, which cluster in this cohort. In well-controlled patients, the
discovery of microalbuminuria after 15 years of diabetes would be typical of the natural history of this complication.
The issue surrounds the validity of this screening result. Urinary albumin excretion rates are highly variable, being affected
by infection, posture and exercise, and this means that sampling procedures are very important. The test should be
performed on a first-voided urine sample and, if positive, infection should be excluded by culture. If microalbuminuria is
confirmed then a timed overnight collection should be arranged for assessment of the albumin excretion rate and, if this is
also positive, a further two overnight collections should be organized. No treatment should be instituted on the basis of
this one-off finding.
of agent?
A2
Evidence supports the use of ACE inhibitors to delay the progression of microalbuminuria towards diabetic nephropathy,
even in the presence of normal BP. However, a further consideration in this case is that ACE inhibitors should not be used in
pregnancy and so appropriate contraceptive measures should be instituted before prescription is considered.
32 Diabetes
A3
Once a definitive diagnosis has been made, annual screening is probably satisfactory. This is definitely the case if the repeat
urine tests are negative. If a diagnosis of persistent microalbuminuria is made and the patient opted to take an ACE
inhibitor, sequential urine testing is unlikely to alter management. Hence, yearly screening as part of the annual review
would be appropriate.
A4
This person has no evidence of CHD and she is currently normotensive, non-smoking and lean. In this age group there is no
evidence to support the use of long-term lipid-lowering therapy or aspirin, and she has good glycaemic control. Apart from
advice on keeping her weight under control and taking regular exercise, no other issues need to be addressed.

OSCE COUNSELLING CASE 1.7 – ‘As someone with late-onset diabetes, should I be
taking aspirin?’
‘Late-onset diabetes’ is an old term for ‘non-insulin-dependent diabetes’, now termed ‘type 2 diabetes mellitus’. The short
answer to the question is ‘probably yes’ unless there is a known contraindication to the use of aspirin. This advice, however,
is based more on consensus expert opinion than on trial evidence.
Patients with known CHD should receive secondary prevention with aspirin prescribed at a dose of 150 mg once daily. For
patients with no evidence of CHD, primary prevention with aspirin 75 mg once daily is slightly more controversial. The
American Diabetes Association recommends that all people with diabetes who are aged 30 and over should receive
treatment. In contrast, NICE guidance in the UK suggests that only those patients with > 15 per cent 10-year risk of a
cardiovascular event should be prescribed aspirin and only when their BP is well controlled (systolic BP < 145 mmHg).
A useful compromise is to consider aspirin for primary prevention in all those individuals with diabetes who are prescribed
a statin; this will be a significant and increasing majority.
OSCE COUNSELLING CASE 1.8 – ‘Why is my blood pressure so difficult to control?’

Hypertension is commonly associated with type 2 diabetes, but is difficult to treat to target. This difficulty is made worse by
the lowering of target levels, based on results of large clinical trials. In the UKPDS, BP targets were less stringent than those
that are now advocated (typically 140/80 mmHg in type 2 diabetes); nevertheless, more than one-third of patients required
three or more antihypertensive drugs. This difficulty is accentuated by the current consensus on hypertension management,
which promotes the use of low/moderate doses of multiple classes of BP-lowering agents. The rationale for this is the
epistatic interaction between drug classes (giving a bigger response than using maximal doses of a single agent) and the
reduced incidence of adverse effects when drugs are used at lower doses. Added to this is the tendency for BP to rise with
age and obesity.
All of the major classes of antihypertensive agents can be used in patients with diabetes and raised BP, and all classes
produce an equivalent antihypertensive action and achieve target levels in a similar proportion of patients. Benefits of one
class over another differ according to whether the patient has type 1 or type 2 diabetes, and whether the BP elevation is
part of the syndrome of diabetic nephropathy. So ACE inhibitors may be preferred in patients with type 1 diabetes and
microalbuminuria whereas ARBs may be first choice in patients with type 2 diabetes and proteinuria. However, results of
the ALLHAT study imply that the cardiovascular outcomes are similar irrespective of which class of agent is used and the
most important issue is the reduction of BP.
34 Diabetes
DIABETES EMERGENCIES

Q1: What is the likely diagnosis?
Q2: What investigations would be performed?
Q3: How would the diagnosis be confirmed?
Q5: What are the potential complications?
Q6: What issues need to be addressed when the patient has fully recovered?
Clinical cases
CASE 1.13 – A 77-year-old man who is drowsy and dehydrated with a plasma
glucose of 84 mmol/L.
A 77-year-old man has been found collapsed at home by a care assistant. He was previously independent but known to
have hypertension, angina and osteoarthritis. His regular medication was bendrofluazide 5 mg once daily, atenolol 50 mg
once daily and aspirin. He had been noted to be lethargic over the previous few weeks and had been incontinent of urine
on a couple of occasions. On arrival in the accident and emergency department (A&E) he was drowsy but orientated. Vital
signs were normal but he was clinically dehydrated. Urinalysis showed ++++ glucose, ++ protein and + ketones. Plasma
glucose was 84 mmol/L.
CASE 1.14 – A 32-year-old woman with abdominal pain and vomiting and a
plasma glucose of 22 mmol/L and urinary ketones.
A previously well 32-year-old woman presents to the GP surgery with a 24-hour history of abdominal pain and vomiting.
On direct questioning, she admits to weight loss over the previous 2 weeks, associated with thirst, polydipsia and polyuria.
A fingerstick glucose is 22 mmol/L and urine dipstick testing shows +++ ketones.
CASE 1.15 – A 18-year-old man, known to have type 1 diabetes, who is

unconscious.
An 18-year-old man who is known to have type 1 diabetes is found unconscious in his front garden. He had been playing
football earlier in the day but had not complained of symptoms at that time. The diabetes was treated with four injections
of insulin a day and his control was regarded as excellent.

OSCE COUNSELLING CASE 1.9 – ‘What should I do with my insulin if I develop a
vomiting illness that stops me eating?’
OSCE COUNSELLING CASE 1.10 – ‘What advice do I give to my partner if they

witness me having a “hypo” reaction?’
Key concepts
Hypoglycaemia
Hypoglycaemia in diabetes is caused by an imbalance of insulin (too much), exercise (too much) and glucose (too little).
Patients usually experience warning symptoms and signs of hypoglycaemia, which prompt them to take treatment in the
form of glucose. These are often listed as adrenergic (related to autonomic nervous system) and neuroglycopenic (brain
hypoglycaemia); however, in reality patients will have warnings that are a combination of the two.
Adrenergic: sweating, palpitations, hunger, tachycardia
Neuroglycopenic: dizzy, faint, confused, abnormal behaviour, unconsciousness
Hyperglycaemia
Hyperglycaemia in type 1 diabetes may develop into diabetic ketoacidosis (DKA) and in type 2 diabetes hyperosmolar, non-
ketotic pre-coma or coma (HONK).
Hyperglycaemic coma may be a presenting feature of diabetes or the result of intercurrent illness, manipulation of insulin
(usually DKA) or concomitant medication (HONK). In many cases, the cause remains unknown.
Symptoms include lethargy, thirst, polydipsia, polyuria, nocturia, blurred vision and diminished conscious level although
unconsciousness is uncommon (< 5 per cent). Patients with DKA hyperventilate (as a result of the acidosis) and have
sweet-smelling ketones on their breath. They may also have mildly raised plasma glucose levels, so the severity of their
condition should not be judged on this measure. Abdominal pain, masquerading as an acute abdomen, is frequently
present.
In HONK, patients are severely dehydrated and glucose levels are always very high. The prognosis in HONK is poor as a
result of the concomitant illnesses (CHD, renal disease, cardiovascular disease [CVD]) seen in this usually elderly cohort.
36 Diabetes
Answers
CASE 1.13 – A 77-year-old man who is drowsy and dehydrated with a plasma
glucose of 84 mmol/L.
A1
Hyperosmolar, non-ketotic coma, which usually affects older people with type 2 diabetes and can be the presenting feature
(as in this case). Precipitating causes include concurrent medication, including thaizide diuretics, and inter-current illness (a
UTI being possible in this scenario). Although termed ‘coma’, it is unusual for patients to be unconscious. Although this
patient has + ketones, this is unlikely to represent acidosis where > ++ urinary ketones would be expected. Extremely high
plasma glucose levels may be seen.
A2
Venous blood for plasma glucose, U&Es, osmolality, bicarbonate, amylase and full blood count (FBC).
Arterial blood gases (ABGs)
Culture of urine and venous blood (and sputum if available)
Chest radiograph
ECG.
A3
Hyperglycaemia has already been demonstrated. Hyperosmolality can be confirmed after U&E results are available using
the formula: [2(Na+ + K+) + urea + glucose] > 350 mmol/L. Plasma ketones should be within normal limits and there
should be no acidosis confirmed by ABGs (or venous bicarbonate).
A4
Attention to airways, breathing and circulation, as necessary
Intravenous access and set up an intravenous infusion
Cardiac monitor
Treatment should then be given with intravenous insulin and intravenous fluids while monitoring electrolytes (Box 1.1)
A nasogastric tube should be inserted and the patient should be fully anticoagulated with heparin
Consideration should be given to central venous pressure (CVP) monitoring, urinary catheterization and broad-
spectrum antibiotics.
Box 1.1 Hyperosmolar, non-ketotic coma (HONK)

Insulin management of HONK
Insulin 3 units/h via intravenous pump
Monitor glucose hourly using meter and laboratory testing
Aim for fall in glucose level of 3–6 mmol/h
At plasma glucose < 12 mmol/L, reduce to 1.5 units/h
Continue insulin infusion for at least 24 h
Fluid management of HONK guided by central venous pressure line

Intravenous 0.9 per cent saline if Na+ < 160 mmol/L:
– 1 L in 1 h Hour: 1 1 L
– 1 L in 2 h Hour: 3 2 L
– 1 L in 2 h Hour: 5 3 L
– 1 L in 4 h Hour: 9 4 L
Thereafter 4 hourly
Change to 5 per cent dextrose when plasma glucose < 12 mmol/L
Electrolyte (K+) management of HONK

No K+ in litre 1, pending laboratory reading:
– usually K+ 3.5–5.5 mmol/L – ADD 20 mmol/L
– recheck 2 and then 4 hourly
– if K+ > 5.5 mmol/L – NO K+ – recheck 1 h
– if K+ < 3.5 mmol/L – ADD 40 mmol/L – recheck 1 h
If Na+ > 160 mmol/L, use half 0.9 per cent saline
A5
The prognosis for HONK remains poor (20–30 per cent). Patients are at high risk of thromboembolism and congestive
cardiac failure as a result of the fluid regimen. As a result of age and co-morbidity, IHD, renal failure and stroke are
common. Aspiration of gastric contents may occur in the setting of reduced consciousness.
38 Diabetes
A6
Despite the level of presenting glycaemia, management of the diabetes often does not involve insulin and some patients
manage on diet only. The patient needs to be given dietary advice as well as specific diabetes education on issues such as
monitoring, foot care, etc. This would usually involve the specialist diabetes nurse and a dietitian. Other aspects of
cardiovascular risk need to be assessed and, in this case, BP medication may be changed from high-dose thiazide to an
alternative class of agent (such as an ACE inhibitor).
CASE 1.14 – A 32-year-old woman with abdominal pain and vomiting and a
plasma glucose of 22 mmol/L and urinary ketones.
A1
Diabetic ketoacidosis. This is an emergency complication of type 1 diabetes and can be the presenting feature, as in this
scenario. Precipitating causes include intercurrent illness, e.g. UTI, and withholding insulin (in an established case).
Abdominal pain and vomiting are not uncommon and can lead to the erroneous diagnosis of an acute abdomen.
A2
Venous blood for plasma glucose (to confirm the fingerstick test), U&Es, osmolality, bicarbonate, amylase and FBC
Plasma ketones may become a more widely used test with the arrival of near patient analyses
ABGs
Culture of urine and venous blood
Chest radiograph
ECG.
A3
Confirmation of hyperglycaemia with ketonuria and acidosis (pH < 7.2, H+ > 63 mmol/L). Note that the hyperglycaemia is
often not pronounced and, indeed, may be absent.
A4
The patient should be admitted to hospital. Intravenous access should be established for blood tests and infusion and a
cardiac monitor attached. Treatment should then be given with intravenous insulin and intravenous fluids while monitoring
electrolytes (Box 1.2).
Box 1.2 Diabetic ketoacidosis (DKA)
Insulin management of DKA

• Insulin: 6 units/h via intravenous pump
• Monitor glucose hourly using meter and laboratory testing
• Aim for fall in glucose level of 3–6 mmol/h
• At plasma glucose < 12 mmol/L, reduce to 2–3 units/h
• Continue insulin infusion for at least 24 h and no urinary ketones
Fluid management of DKA
• Intravenous 0.9 per cent saline:

– 1 L in 1 h Hour: 1 1 L
– 1 L in 1 h Hour: 2 2 L
– 1 L in 2 h Hour: 4 3 L
–1 L in 2 h Hour: 6 4 L
– 1 L in 4 h Hour: 10 5 L
• Thereafter 4 hourly
• Change to 5 per cent dextrose when plasma glucose < 12 mmol/L
Electrolyte (K+) management of DKA

• No K+ in litre 1, pending laboratory reading:
– if K+ > 5.5 mmol/L – NO K+ – recheck 1 h
– if K+ < 3.5 mmol/L – ADD 40 mmol/L – recheck 1 h
– if K+ 3.5–5.5 mmol/L – ADD 20 mmol/L – recheck 2 and then 4 hourly
A5
The prognosis for DKA should be good, given that it affects young people who rarely have other significant co-morbidities.
Cerebral oedema may occur during treatment, although the cause of this complication is unknown. Aspiration of gastric
contents may occur in the setting of reduced consciousness.
40 Diabetes
A6
The diagnosis of DKA implies that the patient has type 1 diabetes and will require life-long insulin. She will therefore need
to be educated about the condition, taught to inject insulin and how to self-monitor using fingerstick testing. She will need
to be given information about the immediate complications of her condition (hypoglycaemia, DKA) and advised to avoid
pregnancy until good glycaemic control is achieved. Ultimately she will need to understand the long-term risks of small and
large vessel disease. These issues are best addressed by a diabetes nurse specialist and a formal education programme.
CASE 1.15 – A 18-year-old man, known to have type 1 diabetes, who is

unconscious.
A1
Hypoglycaemia. As a general rule, an unconscious person with diabetes is hypoglycaemic until proved otherwise. This
diagnosis is very likely in an otherwise fit young person who takes insulin. Precipitating factors in this case may be the
exercise earlier in the day (the effects of exercise can last for many hours) and tight glycaemic control, which may provoke
hypoglycaemia unawareness.
Refer to Q3 answer.
A2, A3
Fingerstick blood glucose testing should confirm the diagnosis and is sufficient to allow initiation of treatment.
A4
In an unconscious patient the two main options are administration of glucagon or intravenous dextrose. Glucagon may be
available because patients with type 1 diabetes are encouraged to keep a supply for this type of emergency. It comes as a
powder that must dissolved in water (a vial of sterile water is part of the kit). One vial = 1 mg = 1 unit, which is the
standard injection, usually into muscle (but it can be subcutaneous or intravenous).
Intravenous dextrose is given by diluting 50 per cent dextrose to half-strength and injecting 50 ml via a cannula. An
infusion of 5 per cent dextrose is then set up to reduce the risk of phlebitis.
A5
Patients can suffer injury if they have lost their warnings of hypoglycaemia. In older patients, hypoglycaemia may present
with neurological signs typical of stroke. Death is thought to be uncommon in this setting, although hypoglycaemia has
been implicated in the higher incidence of the ‘dead-in-bed’ syndrome seen in type 1 diabetes. With regard to the
treatments, intravenous dextrose can cause phlebitis and glucagon is associated with nausea and vomiting.
A6
Need to find out the cause of the event (too much insulin, too much exercise or too little food) and then provide education
in order to prevent future recurrence. In this case, the active issues would be manipulation of the treatment regimen to be
able to cope with exercise and possibly a relaxing of glycaemic control in order to reduce the risk of hypoglycaemia and
decrease hypoglycaemia unawareness.
42 Diabetes

OSCE COUNSELLING CASE 1.9 – ‘What should I do with my insulin if I develop a
vomiting illness that stops me eating?’
The issue here is what most people with diabetes refer to as ‘sick day rules’. Patients will understandably be concerned that
they may become hypoglycaemic by taking insulin without food. However, any intercurrent illness can cause blood glucose
levels to rise, probably by increasing insulin resistance. Hence the advice that ‘YOU SHOULD NEVER STOP INSULIN’.
Clearly they should perform more frequent fingerstick testing, at least 4 hourly. This will allow detection of hypoglycaemia
and if, as is likely, glucose levels rise then additional insulin (rapid acting) may be needed.
For patients with type 1 diabetes, vomiting should raise the possibility of DKA and urine ketones should be checked at least
twice daily. If these are positive to +++ or more then medical advice, and probably admission to hospital, must be sought.
In young people with type 1 diabetes, dehydration can develop very quickly and a low threshold for seeking medical advice
should be promoted.
Patients should be aware of the actions to take during illness and how to access appropriate advice (not NHS Direct). This
will mean telephone numbers of the diabetes specialist nurse team and agreed guidelines for out-of-hours management of
diabetes emergencies
OSCE COUNSELLING CASE 1.10 – ‘What advice do I give to my partner if they

witness me having a “hypo” reaction?’
Symptoms of hypoglycaemia include lack of concentration, bad temper, change in behaviour, confusion and pallor, all of
which are easily (perhaps more easily) recognized by a third party. Hence it is vital that the partner of someone with
diabetes be aware of the symptoms and signs of hypoglycaemia and able to take appropriate action.
If the partner suspects hypoglycaemia ideally he or she should encourage the person with diabetes to check a fingerstick
glucose level. However, there is little to be lost by instituting treatment without confirmation of the diagnosis. Assuming the
person with diabetes is alert this involves taking food by mouth, usually in the form of glucose tablets: 10 g glucose is
equivalent to three sugar lumps or one Dextrosol tablet. Patients with diabetes should always carry some form of glucose
replacement and Dextrosol tablets are recommended because they are less palatable than sweets (and so less likely to be
consumed during normoglycaemic periods). Alternatives include 200 mL milk or 100 mL Coca-Cola (not Diet Coke). A
longer-acting carbohydrate such as bread or biscuits should then be consumed.
If the patient is semi-conscious a glucose gel can be administered via the buccal membrane. Hypostop is a glucose gel
supplied in a plastic bottle with a nozzle. The gel can be squeezed into the mouth between the teeth and cheek, and is
absorbed into the circulation without the need for swallowing.
If the person with diabetes is unconscious he or she should be placed into the recovery position. If the partner has been
trained, glucagon can be administered (see above), otherwise, medical aid should be summoned.
Perhaps the most important advice to the partner is not to panic and he or she should be reassured that the normal
outcome of a ‘hypo’ is that blood glucose levels rise in response to the body’s natural adrenergic response.
2Endocrinology
Andrew Levy
44 Endocrinology
HYPERTHYROIDISM
? Questions for the clinical case scenario given
Q1: What do you think the likely diagnosis is?

Q2: What tests could you do to confirm this?
Q3: What tests would help establish the cause?
Q4: What is the initial management?
Q5: What are the long-term complications/sequelae?
Clinical case
CASE 2.1 – A 26 year-old-receptionist presents with palpitations and weight loss.
Although pleased about the latter, she is concerned that her menstrual periods have stopped and it is the anxiety related to
this, she believes, that is responsible for disturbing her sleep. Her partner has insisted that she seek a medical opinion.

OSCE COUNSELLING CASE 2.1 – ‘Do I have to have surgery?’
OSCE COUNSELLING CASE 2.2 – ‘Will I be able to have children after radioiodine
treatment?’
Key concepts
Graves’ disease is an autoimmune condition characterized by thyroid overactivity, eye changes (Graves’ infiltrative
ophthalmopathy or more specifically ‘orbitopathy’) and skin changes (pretibial myxoedema and finger clubbing, known
as thyroid acropachy). The three components may occur in isolation, in any combination or never. Their clinical courses
are usually independent and unpredictable. Skin changes are rare. Note that ‘myxoedema’ was an old term for thyroid
underactivity. It is now a term reserved for the skin changes that sometimes occur in Graves’ disease.
In all hyperthyroid patients (even if iatrogenic), sympathetic overactivity leads to retraction of the upper lid with
widening of the gap between the upper and lower lids when the eyes are open (the palpebral fissure). Increased
exposure of the cornea and conjunctiva leads to grittiness and soreness of the eyes.
Hyperthyroidism 45
In Graves’ orbitopathy, which can occur without hyperthyroidism, autoimmune-mediated infiltration of the contents of
the orbit and periorbital tissue leads to non-pitting and boggy soft tissue swelling, with increased volume of
extraocular muscles, connective tissue and fat. This pushes the globe of the eye forward and can interfere with the
function of the extraocular muscles, optic nerves and eyelids, reducing protection afforded by the tear film and leading
to double vision and even blindness.
Hyperthyroid patients tend to be sweaty, tremulous, anxious and sometimes rather aggressive. Proximal myopathy
(weakness of the thigh and arm muscles) makes their muscles ache and although tired, sleeping is often difficult. Appetite
is increased, weight tends to decrease and stools are often softened but not frankly diarrhoeal. Fertility is reduced, and
menstrual periods become lighter or stop altogether. Patients often find that their short-term memory is impaired, and it
becomes difficult sometimes for them to make rational decisions.
In addition to sore eyes, the patient may complain of fast palpitations. If present, a thyroid bruit (the sound of blood
rushing through the highly vascular, overactive gland) is a useful sign because it excludes thyroiditis and exogenous thyroid
hormone as causes of hyperthyroidism.
46 Endocrinology
Answers
CASE 2.1 – A 26-year-old receptionist presents with palpitations and weight loss.
A1
Hyperthyroidism would fit all of the symptoms here and, as it is very common, it is certainly an important diagnosis to
confirm or refute. There are differential diagnoses of course, and panic attacks, agitated depression, tachyarrhythmias such
as paroxysmal supraventricular tachycardia, atrial fibrillation or flutter, or excessive caffeine or other stimulant ingestion,
could be responsible for some, if not all, of the symptoms. Of course, anyone taking thyroxine surreptitiously or being
prescribed an excessive dose for treatment of hypothyroidism may also present in this way. Much rarer conditions such as
phaeochromocytoma should also be kept in mind.
A2
Laboratories vary in the thyroid function tests that they’re willing to run for screening, but all would provide a measure of
thyroid-stimulating hormone (TSH), which is suppressed by most causes of thyrotoxicosis. A free thyroxine (FT4) is also
useful, and will be raised above the upper limit of normal in hyperthyroidism. Unusually for tests of endocrine function, the
TSH and fT4 are very reliable and single samples taken at any time of day will be representative of thyroid function.
A3
Clinically, the presence of Graves’ eye disease establishes the diagnosis in a patient presenting with thyrotoxicosis, and no
further investigations need to be done. Similarly, if a thyroid bruit is present, this too is unequivocal evidence of primary
hyperthyroidism, and excludes thyroiditis and the effects of exogenous thyroid hormones. Thyroid autoantibodies
(antimicrosomal antibodies) are usually present, but this test is not often particularly helpful.
Imaging the thyroid either using ultrasonography or isotope scans is not often required in patients presenting with
hyperthyroidism. Confirming the presence of a solitary ‘hot nodule’, however, can be useful because radioiodine is a more
appropriate treatment than antithyroid medication, which although effective, would have to be continued in the long term
to maintain euthyroidism.
A4
In this case, after suitable explanation of the various options, treatment with carbimazole at 40 mg daily, to which
thyroxine (100 µg daily) is added after a couple of weeks is probably the most secure route to rapid restoration of
Hyperthyroidism 47
euthyroidism. The patient must be warned that carbimazole can cause dangerous neutropenia idiosyncratically, and that
the first sign of this is a sore throat. If this symptom occurs, the patient must be advised to stop the drug immediately and
seek medical advice.
An alternative to the block and replace regimen described above is to treat with carbimazole alone and repeat thyroid
function tests regularly, every 3–4 weeks, and to reduce the dose of carbimazole as the condition comes under control,
aiming for a dose of 5–10 mg daily after 2–3 months.
A5
Abnormalities of thyroid function are very common and highly amenable to treatment. However, we often forget just how
uncomfortable these conditions can be for the patient. Graves’ eye disease, for example, can produce major cosmetic
problems even if vision remains entirely unaffected. Primary hyperthyroidism often takes well over a year, if not longer, to
treat effectively, and during this time the patient’s ambient thyroid hormone levels, symptoms and mood often fluctuate
uncomfortably.
Persistent hyperthyroidism is associated with osteoporosis, proximal myopathy and cardiomyopathy, manifesting as atrial
fibrillation and its associated increase in thromboembolic risk.
48 Endocrinology

OSCE COUNSELLING CASE 2.1 – ‘Do I have to have surgery?’
In the past, subtotal thyroidectomy was extensively used to treat hyperthyroidism. Radioiodine is a very effective treatment
and antithyroid drugs are also safe to use in the long term if a patient objects to radioiodine, or if there is concern that
radioiodine might worsen Graves’ orbitopathy. Thyroid surgery is reserved for patients in whom very rapid and permanent
control of hyperthyroidism is required, or in whom a goitre is causing compressive or cosmetic problems.
It is hoped that early and aggressive immunosuppressive treatment, principally with prednisolone, will reduce the frequency
and extent of surgery required to correct problems associated with Graves’ orbitopathy.
OSCE COUNSELLING CASE 2.2 – ‘Will I be able to have children after radioiodine
treatment?’
It is a commonly held misconception that radioiodine has an adverse effect on fertility, or that having children is inadvisable
after radioiodine treatment. Neither is true. The only caveats to radioiodine use in this respect are that radioiodine has
exactly the same effect on the thyroid of the developing fetus as it does on the mother. It is therefore vital that radioiodine
is not inadvertently given to a woman who is pregnant. Health and safety regulations also seek to limit third-party
exposure to irradiation and, for that reason, it is not an ideal treatment for anyone who cannot at least temporarily escape
spending a great deal of time in close proximity to young children.
ADDISON’S DISEASE (AUTOIMMUNE ADRENAL FAILURE)

Clinical case
CASE 2.2 – A 19-year-old student presents with an 18-month history of
progressive tiredness, weight loss and lethargy.
One year before presentation she had a common cold that forced her to stay away from lectures for 2 days. Three months
before presentation, another common cold laid her low for almost 2 weeks, during which time she lost 3 kg in weight. The
local student health doctors had assured her that the symptoms were the result of either being pregnant or taking drugs.
On examination, she was noted to have darker skin than her mother and pigmented palmar creases.

OSCE COUNSELLING CASE 2.3 – ‘Why did this happen to me?’
OSCE COUNSELLING CASE 2.4 – ‘How will it affect my life?’
Key concepts
Before steroids (glucocorticoids) became available, autoimmune destruction of both adrenal glands invariably led to death
from circulatory collapse. In much the same way that the autoimmune destruction of pancreatic islets, which characterizes
type 1 diabetes mellitus, does not become apparent until many months after it starts, autoimmune destruction of the
adrenal glands has usually been advancing for many months by the time it’s recognized. In retrospect, the patient may
have noticed progressive impairment of the ability to respond appropriately to stress, and that it is taking longer to recover
from trivial illnesses such as the common cold.
Both adrenal glands, including the zona glomerulosa, the aldosterone-producing and the angiotensin II responsive layer,
are entirely destroyed in primary adrenal failure. Consequently, the patient becomes critically deficient in both
50 Endocrinology
glucocorticoids (cortisol) and mineralocorticoids (aldosterone), resulting terminally in profound hyperkalaemia and
hyponatraemia. Lack of glucocorticoid feedback at the level of the hypothalamus and pituitary leads to a marked increase
in adrenocorticotrophic hormone (ACTH), which stimulates skin melanocytes. By making the patient look suntanned, the
increase in skin pigmentation (including parts that are not exposed to the sun and new scars) tends to disguise the fact
that the patient is gravely ill, and it can be surprisingly easy to overlook or ascribe the associated history of weakness,
weight loss and intermittent vomiting to other causes.
In secondary adrenal failure (i.e. resulting from pituitary failure), lack of glucocorticoids is not as absolute, and catastrophic
inability to respond to stress is rare. In addition, as ACTH levels are low rather than high, pigmentation does not occur and
mineralocorticoid production is only modestly impaired because it is controlled by the renin–angiotensin–aldosterone
pathway rather than the pituitary.
Answers
CASE 2.2 – A 19-year-old student presents with an 18-month history of
progressive tiredness, weight loss and lethargy.
A1
This is a fairly classic presentation of Addison’s disease. It is relatively easy in retrospect to put the symptoms and signs of
Addison’s disease together, but it can be very difficult to recognize, particularly in its early stages, when adrenal function is
only suboptimal under stress. Delay in diagnosis is therefore very understandable.
A2
The characteristic biochemical changes of hyperkalaemia and hyponatraemia tend to occur relatively late and, if the
diagnosis is suspected, it is perfectly acceptable to start treatment with glucocorticoids immediately, pending an
opportunity to carry out a diagnostic test. The confirmatory test (Synacthen) is described below under OSCE Counselling
Case 2.3.
A3
In the developed world at least 80 per cent of cases of Addison’s disease are caused by autoimmune destruction of the
adrenal glands. Tuberculosis (TB) remains a relatively common cause of Addison’s disease in the absence of autoimmune
disease, and is suggested by the presence of enlarged adrenal glands with necrotic areas and often dots of calcification
visible on computed tomography (CT). In male children (aged < 16 years), X-linked adrenoleukodystrophy, diagnosed by
measuring an increase in circulating very-long-chain fatty acids, is a common and important cause of adrenal failure. In
older patients, measurement of anti-cardiolipin antibodies, a marker of primary anti-phospholipid syndrome, is useful if
features such as recurrent venous thrombosis suggest that the condition is not idiopathic.
In primary adrenal failure, a random plasma ACTH will be high. In secondary adrenal failure, the symptoms and signs
related to the condition are usually much more subtle and the biochemical signs do not appear. ACTH will be low or low
normal and the cortisol response to exogenous ACTH will be suboptimal.
A4
Glucocorticoid replacement (usually with 15 mg hydrocortisone first thing in the morning and another 5 mg at around
4pm) is required immediately and in primary Addison’s disease, mineralocorticoid replacement with fludrocortisone
52 Endocrinology
50–100 µg/day is also required. As Addison’s disease is often disclosed by an episode of acute stress, it is not uncommon
for glucocorticoid treatment to be given parenterally and at a higher dose at least initially.
A5
Patients with autoimmune Addison’s disease are more likely to suffer other autoimmune diseases, and a proportion of them
claim to ‘not feel right’ despite what appears to be adequate replacement therapy. Under conditions of stress, patients
should be asked to step up their glucocorticoid dose by two- or threefold for a few days; they are asked to wear a
MedicAlert bracelet or necklace and carry an injectable form of glucocorticoid with them to use if they find themselves
unable to take oral steroids. For some patients, a longer-acting glucocorticoid such as prednisolone seems to be more
comfortable than the short-acting hydrocortisone.

OSCE COUNSELLING CASE 2.3 – ‘Why did this happen to me?’
All patients with autoimmune Addison’s disease have detectable adrenal cortex and/or steroid 21-hydroxylase
autoantibodies. The specific HLA (human leukocyte antigen) subtypes, HLA-A1, -B8 and -DR3 predispose to developing the
condition. Having said that, it is not clear why some patients develop the condition and others do not. The risk of
developing other autoimmune conditions such as type 1 diabetes mellitus, primary gonadal failure, hypoparathyroidism,
Hashimoto’s thyroiditis, vitiligo and pernicious anaemia is modestly increased in patients with Addison’s disease.
If the diagnosis is suspected in an ill patient, formal diagnosis can wait and immediate treatment with glucocorticoids is
usually appropriate. A high plasma ACTH in the presence of low random cortisol is often sufficient to confirm the diagnosis.
If doubt remains, a cortisol response of less than 495 nmol/L 1 h after a 250 µg intravenous bolus of synthetic ACTH
(Synacthen) confirms the diagnosis.
OSCE COUNSELLING CASE 2.4 – ‘How will it affect my life?’

For most patients the diagnosis of Addison’s disease has no adverse long-term effects on life or lifestyle. Some patients,
however, claim not to feel as well as they did before the onset of overt disease, despite optimized glucocorticoid and
mineralocorticoid replacement. For some of these patients, additional replacement of adrenal pre-androgens has been
advocated, but there is little good evidence to support this at the present time.
The long-term outlook for Addison’s disease is good, provided that the patient is fully aware of the implications of the
condition and the need to respond to stressful situations by temporarily increasing the glucocorticoid dose.
54 Endocrinology
CUSHING’S DISEASE

Clinical case
CASE 2.3 – A 56-year-old woman presents with depression, hirsutism, weight
gain and muscle weakness.
On examination her GP found her to be hypertensive and to have wide, purple striae on her abdomen and thighs. Her
visual fields were full to confrontation and there was no bruising.

OSCE COUNSELLING CASE 2.5 – ‘Will “the tumour” spread to other parts of my
body?’
OSCE COUNSELLING CASE 2.6 – ‘Can I have tablets instead of an operation?’
Key concepts
Hypercortisolaemia (Cushing’s syndrome) is in most cases iatrogenic, an unavoidable side effect of the high-dose
glucocorticoid treatment required for many immune and autoimmune conditions. Rarely, hypercortisolaemia is pituitary
dependent (so-called ‘Cushing’s disease’), and is the result of a pituitary adenoma secreting ACTH. Cushing’s syndrome can
also result from other sources of ACTH such as carcinoid tumours of the lung or gut or from adrenal adenomas and
carcinomas secreting inappropriate amounts of cortisol. It is often surprisingly difficult to identify the source of the problem
with certainty and treat it adequately because even the most careful battery of well-organized investigations can be
misleading. The first task is to confirm the presence of hypercortisolaemia and, if that can be confirmed, investigations are
re-directed to identify the source.
In hypercortisolaemia of malignancy, there may be insufficient time for the typical phenotype to develop. In more chronic
cases, patients characteristically gain weight, develop neuropsychiatric problems (often accentuation of pre-morbid
personality – miserable people become more miserable and vice versa), proximal myopathy (difficulty standing from sitting
without using the arms), muscle wasting, central accumulation of fat (filling in the temporal fossae and development of the
characteristic ‘moon face’ and ‘buffalo hump’), and weakening of the skin leading to the formation of wide, purple stretch
marks (striae) and easy bruisability (although bruises are not often evident in the clinic). Hypertension, hirsutism (caused by
increased ACTH drive to adrenal androgen production) and glucose intolerance are also common. In Cushing’s disease the
ACTH-induced increase in production of adrenal pre-androgens (responsible for the hirsutism) tends to protect against
steroid-induced thinning of the skin.
56 Endocrinology
Answers
CASE 2.3 – A 56-year-old woman presents with depression, hirsutism, weight
gain and muscle weakness.
A1
Although Cushing’s syndrome is suggested by the combination of mental and physical changes listed, the only one that is
specific in the circumstances is the presence of wide, purple striae rather than pale striae. Simple, gross obesity could be
responsible for everything else. Obese people are often depressed about their inability to lose weight, and the shear mass
of tissue to carry around can make them feel weak, even though they tend to be much stronger than an equivalent patient
with hypercortisolaemia. The fat tissue can aromatize pre-androgens to androgens as well as oestrogens, leading to
hirsutism, and of course there is an association between obesity and hypertension, both of which are extremely common.
Cushing’s syndrome is an important diagnosis to make, but it is as well to remember that Cushing’s disease is extremely
rare, compared with simple obesity.
A2
If hypercortisolaemia is suspected, the best screening test available in the UK at the present time is the 24 h urinary free
cortisol, three samples of which should be assayed along with creatinine clearance to ensure that the patient has managed
to produce complete collections. Pregnancy, pain, heavy alcohol ingestion or alcohol withdrawal and vigorous exercise,
particularly if the patient gets up very early every morning and runs, will increase urinary free cortisol to above the normal
range. As cortisol is metabolized by the kidneys during filtration, if the patient drinks more than 5 L of fluid daily, urinary
free cortisol will be high. In addition, some drugs unexpectedly increase urinary free cortisol (e.g. statins) or interfere with
analytical methods, such as co-eluting with cortisol on high-performance liquid chromatography (HPLC) (e.g.
carbamazepine).
A3
Establishing the cause of Cushing’s syndrome can be difficult. Delays associated with various investigations can make it
difficult to carry them out in a logical order without taking an excessive time to reach a conclusion. A peripheral ACTH
measurement is useful because a very high level suggests ectopic ACTH syndrome and a very low level suggests adrenal
disease. Pituitary magnetic resonance imaging (MRI) may show a macroadenoma (a tumour > 10 mm in diameter and/or
distorting the sella turcica), in which case it is very likely to be responsible for the Cushing’s syndrome. Conversely, as the
prevalence of incidental pituitary adenomas < 4 mm in diameter in the general population is very high (probably around 10
per cent), finding one on MRI is insufficient evidence to send a neurosurgeon in after it. CT or MRI of the adrenal glands,
showing a unilateral nodule with contralateral atrophy, suggests a primary adrenal lesion. For many patients, petrosal sinus
sampling, i.e. sampling the venous outflow of the pituitary, is necessary to confirm or refute a pituitary source of excess
ACTH. The level of ACTH should be at least double the level found in peripheral samples taken simultaneously, and should
increase further (to at least three times peripheral levels) in response to corticotrophin-releasing hormone.
A4
The initial management of Cushing’s disease (i.e. pituitary-dependent Cushing’s syndrome) is trans-sphenoidal
microadenomectomy by a skilled neurosurgeon. Obviously, if the problem is a carcinoid tumour of the lungs secreting
ACTH, or an adrenocortical tumour producing too much cortisol, the respective tumours should be removed by an
appropriate specialist.
A5
Unfortunately, cure of Cushing’s disease is difficult to achieve and a large minority of patients relapse at some time or have
only a partial remission and end up with persistent hypercortisolaemia. Improvements in trans-sphenoidal surgery and
endoscopic adrenal surgery should allow a higher percentage of ‘long-term remissions’ in the future, and a reduction in the
prevalence of patients suffering the consequences of persistent hypercortisolaemia, principally osteoporosis and the risks
associated with impaired glucose tolerance or frank diabetes mellitus, hypertension and obesity.
58 Endocrinology

OSCE COUNSELLING CASE 2.5 – ‘Will “the tumour” spread to other parts of my
body?’
Metastatic spread of pituitary tumours has been documented but is extremely rare. The word ‘benign’ is, however, a little
misleading in that some corticotrophic adenomas can infiltrate locally, particularly after bilateral adrenalectomy, which
removes endogenous feedback inhibition of tumour growth (Nelson’s syndrome). It is not unusual for corticotroph
adenoma to be so small that, despite causing dramatic symptoms and signs, they are not visible on pituitary MRI. Even
more curious is the relatively high remission rate when unaffected pituitary tissue is excised at surgery.
Cushing’s disease has such a high risk of recurrence or failure of initial treatment that the word ‘remission’ is used rather
than ‘cure’.
Standard, fractionated linear accelerator (LINAC) pituitary radiotherapy to the remnant reduces recurrence rate about
fivefold, but is associated with a small increased risk of other tumour formation in the radiation field and an increase in the
risk of stroke. It is an important treatment, particularly if the patient has had bilateral adrenalectomy as part of the
management of the condition.
Appropriate treatment of the primary disease does result in weight loss, but many patients find that it is difficult to shed all
of the extra weight that they have accumulated before effective treatment was instigated.
OSCE COUNSELLING CASE 2.6 – ‘Can I have tablets instead of an operation?’

Tablets tend not to be used first line because surgery offers the chance of immediate remission, confirmation of the
diagnosis histologically, and an opportunity to debulk an adenoma that may subsequently be associated with ‘space-
occupying’ problems if allowed to continue to grow in situ. Drugs are used sometimes in preparation for surgery or if
patients have very aggressive disease causing severe neuropsychiatric symptoms, but they are often not very well tolerated.
In the UK, metyrapone is used to inhibit adrenal hormone synthesis competitively. Ketoconazole, the imidazole antifungal
agent, is also a useful adrenocortical hormone synthesis inhibitor, and etomidate, the imidazole anaesthesia-inducing
agent, at very low dose is useful if rapid intravenous control of excessive glucocorticoid levels is required.
Acromegaly 59
ACROMEGALY

Clinical case
CASE 2.4 – A 44-year-old woman presents with excessive sweating and an
increase in hat size over a 3-year period.
She comments that her face and hands just seem ‘bigger’ than before.
Key concepts
Acromegaly is caused by the presence of a growth hormone (GH)-secreting tumour of the anterior pituitary (somatotroph
adenoma) that develops after puberty. Coarsening of the facial features, headaches, sweating and a progressive increase in
jaw, glove, ring and shoe sizes are well-known features of excess GH. The most common and troublesome symptoms are,
however, carpal tunnel syndrome, obstructive sleep apnoea and osteoarthritis, caused by persistent growth of soft tissue
and cartilage. These changes can be partially reversed in some patients when the condition is treated, but, unfortunately,
many of the changes remain and widespread arthritis, caused by disruption of joint cartilage, can be disabling.
If a somatotroph adenoma occurs before increased sex hormones cause the epiphyses of long bones to fuse at puberty, the
patient has the potential to become a giant. In true gigantism, the somatotrophic adenoma not only arises early in life, but
also impairs the function of pituitary gonadotrophs, giving rise to hypogonadotrophic hypogonadism. Without
gonadotrophins (follicle-stimulating hormone [FSH] and luteinizing hormone [LH]), puberty cannot proceed and, if the
epiphyses remain open, persistent growth of long bones can continue throughout life, leading in exceptional cases to
remarkably tall stature.
As GH is primarily involved in the growth of the long bones, whereas sex hormones are responsible for growth of the axial
skeleton, patients with gigantism tend to have very long limbs, but relatively small backs. These so-called ‘eunuchoid’
proportions, where each of the outstretched hands exceeds rather than equals standing height, are also found in other
conditions associated with low sex hormone levels such as Klinefelter’s syndrome (XXY).
60 Endocrinology
Obstructive sleep apnoea
Thickening of the tissues of the nasopharynx predisposes to severe snoring and frequent episodes of complete obstruction
of the airways during the night. This leads to arterial blood oxygen desaturation and increasing respiratory efforts, causing
partial wakefulness until eventually airflow resumes. Consequently, patients frequently complain of tiredness in the
morning. Obstructive sleep apnoea has also been implicated in the pathogenesis of hypertension, which affects over one-
third of people with acromegaly.
Treatment of acromegaly involves trans-sphenoidal debulking of the tumour and in some cases pituitary radiotherapy. Drug
treatment is also used, with long-acting, parenteral somatostatin (GH-release inhibiting hormone) analogues such as
octreotide LAR or lanreotide (Somatuline), dopamine (D2) analogues such as cabergoline or bromocriptine, which reduce
GH and insulin-like growth factor I (IGF-I) levels in about 10 per cent of patients, and GH-receptor blockers (pegvisomant).
Surgery to relieve arthritis, nerve compression syndromes, snoring and facial deformity is also sometimes required. It is
believed that acromegaly is associated with an increased incidence of bowel tumours, and patients in some centres are
offered a routine colonoscopic screening when first diagnosed and at the age of 60 years.
Acromegaly 61
Answers
CASE 2.4 – A 44-year-old woman presents with excessive sweating and an
increase in hat size over a 3-year period.
A1
Acromegaly is likely, of course. It should be remembered that there can be large discrepancies between circulating GH
levels and the phenotypic changes that result. Some patients with very high levels of GH do not seem to develop many of
the phenotypic features of acromegaly. Other patients with only modestly elevated GH levels sometimes continue to grow.
Growth of the hands and feet is relatively pronounced because of the multiple cartilaginous interfaces between the many
small bones. Growth of the skull is minimal and is a feature that is more characteristic of Paget’s disease of bone. In
acromegaly, increased hat size is the result of facial soft tissue growth rather than bony growth, although on radiograph
and CT some skull thickening does occur.
Excessive sweating is also a feature of oestrogen withdrawal and thyrotoxicosis, both of which should be considered
because they are much more prevalent problems, even though neither would explain the rest of this particular patient’s
symptoms.
A2
In many cases, the phenotypic changes of acromegaly are so obvious that little needs to be done to confirm the diagnosis.
The condition might be ‘burnt out’, however, and, as persistent disease is an indication for surgery, it is important to
measure a few random GH levels (three samples 20–30 min apart) and an IGF-I, as well as requesting an MR scan of the
pituitary. The pulsatile nature of GH release means that a single measure of GH is not useful. If doubt remains about the
diagnosis (and it doesn’t usually), failure to suppress GH to < 2 mU/L after 75 g glucose orally confirms the diagnosis.
A3
Rarely, acromegaly is part of the multiple endocrine neoplasia type 1 (MEN-1) syndrome, Carney complex or the isolated
familial acromegaly syndrome. Somatotrophic adenomas have been described in association with GH-releasing hormone-
secreting gangliocytomas in the region of the pituitary. However, the cause of acromegaly is ALWAYS a somatotrophic
adenoma secreting too much GH.
62 Endocrinology
A4
In an elderly patient with co-morbidity, in whom somatotroph adenoma is unlikely to cause local, space-occupying
problems, it is perfectly reasonable to do nothing. In a younger patient, trans-sphenoidal microadenomectomy or debulking
of a macroadenoma is still first-line treatment. In terms of GH reduction, drug treatment with somatostatin analogues or
the new GH-receptor blockers has a higher chance of success than surgery, but both are prohibitively expensive and, as far
as we know at the moment, necessitate long-term treatment.
A5
Complications of acromegaly and its treatment are hypopituitarism, local space-occupying issues (such as visual field
changes) and the effects of excessive GH levels on somatic growth and metabolism. Growth hormone is diabetogenic and
acromegaly is associated with hypertension and an enhanced risk of cardiomyopathy (which might be specific to
acromegaly), and respiratory complications related to altered chest shape and movements.
3Rheumatology
Mark Pugh
64 Rheumatology
POLYARTHRITIS

Q1: What is the likely differential diagnosis?
Q2: How would you investigate this case?
Q3: How would you confirm the likely diagnosis?
Q4: How would you initially manage the case?
Q5: What are the principles of long-term management?
Q6: What is the prognosis?
Clinical cases
CASE 3.1 – A 38-year-old man develops painful and swollen hand joints.
A 38-year-old man presents with a 4-month history of pain and swelling of the knuckles, wrists, knees ankles and toes. He
has no significant past history and the GP confirms the swelling of the joints and notes a history of more than 1 hour’s
stiffness of the joints in the morning. Initial blood tests reveal a microcytic anaemia of 11.8 g/dL and a C-reactive protein
(CRP) of 9.6 g/dL.
CASE 3.2 – Pain in the hands, knees and feet in a 46-year-old woman.
A recently postmenopausal woman presents with a 6-month history of pain and swelling in her hands, knees, neck and
feet. The pain limits her ability to use her hands, and the knee and foot pain limit mobility. Apart from her joint pain she is
otherwise well and there is no contributory past medical history. Examination demonstrates tender double bumps over the
ends of her fingers, especially the index and middle finger, tenderness around the base of the thumb, limited neck
movement, crunching knees with swelling and bilateral early bunions.
CASE 3.3 – Knee pain in a schoolgirl.

A 16-year-old girl has a 6-year history of intermittent knee pain. She presented previously at the age of 10 also for knee
pain, which was attributed to growing pains. Now she describes pain in the knees worse at the end of the day and
especially bad after exercise. Her knees are often sore after sitting and difficult pain on ascending stairs has adversely
affected school attendance. Knee swelling occurs sometimes. She also has pain in her hands, elbows and tops of her legs.
Her joints often click so loudly that others pass remarks. She seems well in other respects and, apart from the previous
assessment for knee pain, there is no past medical history. Her general practitioner detected no obvious joint problem and
the full blood count (FBC), erythrocyte sedimentation rate (ESR) and rheumatoid factor (RF) were reported as normal.
Polyarthritis 65
OSCE Counselling Case

OSCE COUNSELLING CASE 3.1 – What can be done if I get a flare-up of my
rheumatoid arthritis?
Key concepts
Patients generally describe any pain around a joint as ‘arthritis’. Arthritis, by definition, means inflammation of the joint and
therefore in the absence of confirmatory signs should not be diagnosed. Arthralgia is the name for a painful joint without
signs of inflammation. Pain can also be referred as well as originating from ligaments, tendons, muscles, nerves, arteries
and skin around the joint.
There are a wide number of causes of arthritis which include:
degenerative: osteoarthritis
trauma
infective: viral, septic, reactive, parasitic, fungal
endocrine: hypothyroid, hyperthyroid, hyperparathyroid
malignancy: paraneoplastic, secondary or primary malignancy
allergic: erythema nodosum, drug induced
autoimmune: connective tissue disease, seronegative arthritis, vasculitis
crystal arthritis: gout and pseudogout
congenital: Stickler’s syndrome.

66 Rheumatology
Answers
CASE 3.1 – A 38-year-old man develops painful and swollen hand joints.
A1
With a history of multiple, small joint swelling, more than 60 min of morning stiffness and a raised ESR, rheumatoid
arthritis is a likely diagnosis. Other causes of arthritis need to be considered such as other connective tissue disorders,
seronegative arthritis, infection, endocrine disorders, drugs and malignancy.
A2
A full history and examination are important. Examination should confirm the presence of inflammation of the joints
characterized by pain and swelling. All the joints should be examined as well as other systems, looking for evidence of
systemic involvement and, of course, other possible causes of the arthritis apart from rheumatoid arthritis.
A3
The diagnosis is clinical, with the presence of inflammation in the characteristic joints being sufficient to indicate it. The
American College of Rheumatology Diagnostic criteria are often quoted, but the inclusion of erosions and rheumatoid
nodules means that these criteria have low sensitivity in early disease. The presence of a high CRP and/or a positive RF are
not always present in early disease, but if present suggest a likelihood of progression to early erosions.
A4
The initial management should be clinically to confirm the diagnosis and then perform baseline investigations including
FBC, CRP (or similar measurement of inflammation), urea and electrolytes (U&Es), liver function tests (LFTs), and screen for
RF and antinuclear factors. These tests should be consistent with rheumatoid arthritis and should not suggest an alternative
diagnosis. The tests are also useful because many of the drugs used to treat rheumatoid arthritis are toxic. Radiographs of
the hands and feet, and any other involved joints and chest, will often not demonstrate change but will be useful to
monitor disease progression. The use of analgesics and anti-inflammatory drugs may provide some symptom relief while
baseline investigations are undertaken. When confirmed rheumatoid arthritis patients should be offered disease-modifying
anti-rheumatoid drugs (DMARDs) such as methotrexate, without delay to prevent the development of joint damage.
Polyarthritis 67
A5
The ongoing management of rheumatoid arthritis involves ensuring complete control of inflammation, monitoring joint
damage, checking for other systemic manifestations and screening for the development of treatment side effects. As with
the development of any chronic illness, patient education about the illness and its treatment is important to allay fears and
promote treatment compliance.
A6
Extra-articular manifestations of rheumatoid arthritis include:
skin: ulcers and nodules
lung: fibrosis, effusions and nodules
neurological: myopathies and neuropathies
eye: secondary Sjögren’s syndrome and inflammation
systemic: anaemia, weight loss and fevers
skeletal: osteoporosis,
cardiovascular: high incidence of cardiovascular disease and rare muscle, valve or pericardial involvement.
The progress for joint damage is: 5–10 per cent of patients do not develop damage; the rest do with 40–70 per cent after
a chronic disease course and developing significant levels of damage and disability, and 20–40 per cent after a relapsing
and remitting course associated with lesser levels of damage.
CASE 3.2 – Pain in the hands, knees and feet in a 46-year-old woman.
A1
There is a wide differential; however, the presence of Heberden’s nodes in the hands, a characteristic pattern of joint
involvement and the absence of synovitis point to a diagnosis of osteoarthritis.
A2
Blood tests are not essential, but will help rule out alternative diagnoses. Radiographs of the symptomatic joints may
demonstrate the typical changes of joint space narrowing, subchondral sclerosis, bone cysts and osteophytes.
68 Rheumatology
A3
A history and examination should be sufficient to rule out alternative diagnoses and confirm the diagnosis. A radiograph is
probably the most useful diagnostic test, but early changes can be subtle and it is possible to have osteoarthritis co-
existing with gout or an inflammatory arthritis.
A4
Conservative measures should be addressed, including weight control, the use of padded footwear, e.g. trainers, and
regular exercise. A walking stick can help knee symptoms and orthoses will help foot symptoms. Physiotherapy can alleviate
local symptoms. Topical non-steroidal anti-inflammatory drugs (NSAIDs) or capsaicin cream provides some relief. Intra-
articular steroids are safer than NSAIDs and may be appropriate to relieve joint symptoms. Analgesics are safer than
NSAIDs and patients should always be encouraged to use paracetamol as a first-line drug. There is some evidence that
complementary therapy may provide some symptom relief, with glucosamine probably having the best scientific basis.
A5
The complications of osteoarthritis relate to the development of disability secondary to joint involvement. Patients can be
reassured that, although activity may produce increased symptoms, only heavy manual work or professional level sports
activity will accelerate joint damage. Treatment may produce complications, which may require treatment, of which NSAID-
induced gastrointestinal damage is probably the most common. Surgery, especially of the knee and hip, is very successful
for patients with significant pain and disability associated with significant radiological damage.
A6
Typically most patients are concerned about the development of future disability but can be reassured that this is very
unlikely The key to successful management is to ensure that the patient self-manages the problem because cure is not
possible and medical disease modification not achievable.
CASE 3.3 – Knee pain in a schoolgirl.
A1
Benign hypermobility is the most likely diagnosis. An underlying inflammatory arthritis is unlikely as a result of the length of
the history, the normal looking joints and the absence of inflammatory marker in the blood, but it needs to be ruled out.
Polyarthritis 69
A2
A history looking for pointers to alternative diagnoses, such as psoriasis, or systemic features of a connective tissue disorder
or juvenile idiopathic arthritis, is important. A family history of joint pains in childhood is often present, highlighting a
familial link in this disorder. Examination of the joints, looking for the absence of joint deformity or ongoing synovitis,
would virtually rule out an underlying inflammatory arthritis. Radiographs and blood tests would be helpful to rule out
alternative diagnoses.
A3
Generalized benign hypermobility is diagnosed by demonstrating hypermobility in classic sites, including being able to bend
the little finger to a right angle, bend the thumb back to touch the forearm, hyperextension of the elbow, and bending
forward and placing the palms of the hands flat on the floor. Although normal on initial examination retropatellar pain can
often be elicited by Clarke’s test (compression of the patella with restricted knee extension). Flat feet are usually present.
More unusual causes of hypermobility, such as Marfan’s and Ehler–Danlos syndromes, should be considered.
A4
Reassurance that this is not the start of a deforming arthritis is usually very important. Anti-inflammatory and analgesic
drugs offer some relief and can be important if the pain is severe enough to disrupt sleep or limit activities. Physiotherapy
can improve pain by limiting joint movement through muscle development. Orthoses to correct flat feet and raise the heel
can improve not only foot and ankle symptoms but also those from the knee, hip and back.
A5
Occasionally these patients can have recurrent dislocations of the shoulder, hip or knee. This may require joint-stabilizing
surgery but if possible should be avoided. On a day-to-day basis most of the problems relate to maintaining normal
functions such as school attendance and physical activity.
A6
Symptoms typically improve with age but improvement is not universal. Benign hypermobility does not appear to be
associated with the development of early osteoarthritis.
70 Rheumatology
OSCE Counselling Case – Answer

OSCE COUNSELLING CASE 3.1 – ‘What can be done if I get a flare-up of my
rheumatoid arthritis?’
Patients can find the psychological impact of flare-ups difficult and need to be reassured that, even with a background of
good control, flare-ups can occur. Sometimes no identifiable reason can be found to explain the flare-up; otherwise a
waning of the effect of current medication, intercurrent infection or stress may be involved. Single joint flare-ups are usually
easier to deal with than multiple joint problems. Patients should be advised to maximize their analgesic and anti-
inflammatory medication, rest the affected joint and use ice packs. With no more intervention, the flare-up may settle. If it
does not intra-articular steroid for a localized problem, or intramuscular, oral or intravenous steroid for a more generalized
flare-up, may be necessary. A change in disease-modifying therapy may be indicated if the flare-up signals a loss of effect
of the patient’s current therapy.
Monoarthritis 71
MONOARTHRITIS

Clinical cases
CASE 3.4 – An elderly man presents with a reddened, very painful and swollen
ankle of short duration.
A 73-year-old man requires an urgent appointment for assessment of a painful left ankle. This started suddenly 2 days ago
and is now so painful that he cannot put his foot to the floor. On examination the ankle is red and significantly swollen,
but the rest of his joints are unremarkable. He has a history of two episodes of pain, redness and swelling of his right big
toe, which settled over 2–3 weeks with NSAIDs and rest. Currently, he is on bendroflumethiazide for treatment of
hypertension but is otherwise fit and well.
CASE 3.5 – ‘It all started when my second toe swelled like a red sausage.’
A 32-year-old woman describes a painful swelling of the second toe. This came on spontaneously 7 weeks ago.
Examination of her other joints, including her back, reveals no abnormality of joint shape or function. While examining her
joints you notice scaling patches of skin, with underlying erythema, over her elbows and knees. She has had these for 3–4
years and has treated it as dermatitis with simple cream. More recently she has noticed some flaking of her toenail on the
end of the painful toe. The rest of the general physical examination is normal.
CASE 3.6 – A 50-year-old man with a painful knee.

A 50-year-old travelling salesman presents with difficult pain in his right knee after he has been driving for more than 1
hour. This has been coming on for the last 3 years. He describes discomfort while walking up stairs and occasional pain in
his knee in bed at night. Typically he has few symptoms earlier in the day but his knee aches by the end of the day. On
review of his muskuloskeletal system, he has a history of low back pain, and pain in the ends of his fingers, the base of the
thumb and big toe. He had a cartilage operation on his right knee at the age of 29 after a football injury.
72 Rheumatology

OSCE COUNSELLING CASE 3.2 – ‘I am not keen on taking medication every day. Is
there anything else I can do to help my
osteoarthritis?’
Key concepts
Monoarthritis is usually caused by a different diagnosis to polyarthritis, although there is some overlap. Septic arthritis is
typically monoarticular and therefore joint aspiration is a more important investigation in this group of patients than in
patients with polyarthritis. Aspiration can both aid diagnosis and be of therapeutic value. Septic arthritis requires prolonged
antibiotic treatment and every effort should be made to confirm the diagnosis before treatment is started. Most peripheral
joints can be aspirated at the bedside; however, hip joint aspiration is usually best done with ultrasonic guidance. Other
causes of monoarthritis include osteoarthritis, crystal arthritis (e.g. gout), sarcoidosis and seronegative arthritis.
Monoarthritis 73
Answers
CASE 3.4 – An elderly man presents with a reddened, very painful and swollen
ankle of short duration.
A1
With a similar history of self-limiting arthritis in the toe and a risk factor for hyperuricaemia with diuretic therapy, the most
likely diagnosis is gout. The diagnosis not to miss is septic arthritis. This could also represent an alternative crystal
arthropathy or an intermittent seronegative or rheumatoid arthritis.
A2
At the time of the attack there is typically a high ESR with raised white blood cell (WBC) and platelet count. The serum
urate is sometimes decreased during an acute attack, producing a falsely normal-looking serum urate level. Hyperuricaemia
is common in gout but not essential and a normal urate level does not exclude it. Factors associated with gout include
alcohol, warfarin therapy, low-dose aspirin, myelproliferative disorders, tumour lysis, psoriasis and renal function. Tophi
show up on radiographs and gout can produce a typical pattern of joint damage, although radiological findings are not
always present.
A3
The definitive diagnostic test would be joint aspiration of the affected joint with the demonstration of urate crystals under a
polarizing microscope; appropriate microbiological assessment should also rule out sepsis. Identification of urate crystals
from another larger and possibly easier to aspirate joint, tophus or bursa would be virtually diagnostic.
A4
The initial management of gout attempts to control pain and promote resolution of the acute attack. Rest is advised and
patients should be well hydrated. If gout is secondary to an underlying medical problem such as renal failure this may need
addressing. Provided that there are no contraindications, medical options include NSAIDs, colchicine, and intramuscular or
intra-articular steroids. If nothing else, the attack should settle spontaneously in 4 weeks.
74 Rheumatology
A5
Prophylactic treatment should not be started until 2–3 weeks after the acute event (due to the risk of exacerbation). Once
recovered from the acute attack it may be necessary to start prophylactic treatment. The most commonly used drug is
allopurinol, which is started in low dose and titrated upwards balanced against normalization of the hyperuricaemia. The
drug is usually well tolerated but, in the event of problems such as rash and occasional leukopenia, alternatives include the
uricosurics probenecid and sulfinpyrazone or low-dose daily colchicine.
A6
Repeated attacks of gout can damage the underlying joint. The associated hyperuricaemia may produce a nephropathy
and/or renal stones. However, provided that the hyperuricaemia can be controlled by correcting the cause or using specific
therapy, the outlook for this condition is very good.
CASE 3.5 – ‘It all started when my second toe swelled like a red sausage.’
A1
The rash is likely to be psoriasis and the dactylitis is most probably associated psoriatic arthritis. Infection and gout can
produce dactylitis.
A2
Examination of the flexures and scalp may reveal additional psoriasis. Further examination of the fingernails may reveal
characteristic nail pitting. A radiograph of the toe will most probably reveal little of diagnostic value but, as psoriatic
arthritis is typically a chronic problem, one should be done for baseline assessment to allow future mapping of possible
damage. Routine blood testing will usually reveal a raised inflammatory response.
A3
The diagnosis is clinical based on a picture of a distal small joint and predominantly lower limb large joint arthritis in
association with, or with a history of, psoriasis. Routine testing should not point to another diagnosis.
Monoarthritis 75
A4
The first aim should be to control her pain. Anti-inflammatory medication may settle the attack; intra-articular steroid
injection may also help. Some patients need to start taking DMARDs to control the problem. Anti-tumour necrosis factor
(TNF) therapy can be used in patients with resistant disease.
A5
This may represent the start of a chronic and possibly more widespread problem requiring long-term therapy. It should
always be borne in mind that in the future she may develop associated ankylosing spondylitis, iritis, inflammatory bowel
disease and genitourinary tract inflammation.
A6
The prognosis depends on the number of joints involved. Limited joint involvement has an excellent long-term outlook,
whereas multiple joint involvement has a prognosis similar to chronic progressive rheumatoid arthritis.
CASE 3.6 – A 50-year-old man with a painful knee.
A1
Based on the history of previous cartilage surgery and pain on exercise at the end of the day, as well as pain in typical sites,
osteoarthritis is the most likely diagnosis.
A2
The most useful single investigation would be a weight-bearing radiograph of the knee. Radiographs of the other sites may
also reveal degenerative changes. Blood tests looking for alternative diagnoses may be helpful.
76 Rheumatology
A3
The absence of any other cause of arthritis and the presence of the typical radiological changes of osteoarthritis, including
joint space narrowing, subchondral sclerosis, subchondral bone cysts and osteophytes, should be sufficient. Examination of
the knee may demonstrate a joint effusion, decreased joint movement with discomfort and possible crepitus.
A4
Aspiration of the knee may ease symptoms, especially when combined with intra-articular steroid injection. Physiotherapy
may be able to relieve symptoms. Simple analgesics and/or NSAIDs may provide additional relief.
A5
Osteoarthritis is not associated primarily with systemic complications but drug treatment is and therefore should be used
judiciously.
A6
Full recovery is unlikely and the chronic nature of the problem may threaten this man’s livelihood. Consideration should be
given to advice about an automatic car or possibly a change in position in his company if his symptoms cannot be helped.
Surgical treatment may be necessary in the longer term but is not inevitable.
Monoarthritis 77

OSCE COUNSELLING CASE 3.2 – ‘I am not keen on taking medication every day. Is
there anything else I can do to help my
osteoarthritis?’
Patient concerns about medication can sometimes be allayed by discussion about the risks and benefits of medication.
Education about the nature of the condition will promote independence. Reducing obesity, minimizing traumatic activity
and using padded footwear will improve the prognosis. Orthoses can improve the symptoms of foot osteoarthritis and a
walking stick can help mobility in patients with knee and hip osteoarthritis. Regular exercise aimed at improving aerobic
fitness, muscle strength and proprioception will also improve mobility. Other forms of physiotherapy can be used to treat
local symptoms. Many patients who dislike the idea of taking oral medication are happy to consider topical treatment in
the form of NSAIDs or capsaicin. Intra-articular steroids or hyaluronic acid derivatives can also help symptoms. Patients
often prefer to take complementary therapy and, in the case of osteoarthritis of the knee, glucosamine is proved to have
modest symptom-relieving properties with safety, and controversially may also improve cartilage.
78 Rheumatology
SYSTEMIC RHEUMATOLOGICAL ILLNESSES

Clinical cases
CASE 3.7 – A young woman with joint pains and feeling unwell.
A 29-year-old woman presents with a 6-month history of pain and swelling, which started in the fingers and wrists and
then spread to her shoulders, knees and ankles. She was treated for pleurisy twice 4 and 3 months ago and since then says
she feels unwell. Most recently she says that she has developed a rash on her cheeks and forehead.
CASE 3.8 – ‘You’ve seen me before with sinusitis. Now I feel terrible, my eye is
sore and I think I coughed up blood today.’
A 49-year-old man feels unwell with temperatures, myalgias, and pain in his wrists, knees and ankles. He is loosing weight
and cannot work. His left eye has become increasingly sore and red. For some time he has had a cough productive of
yellow/white sputum but today coughed up red blood. Investigations reveal a haemoglobin (Hb) of 10.8 g/dL, white cell
count (WCC) of 14.8 × 109/L and ESR of 98 mm/h. Urinalysis demonstrated blood +++ and protein ++. Apart from a 3-
year history of sinusitis requiring antibiotics and nasal spray, there is no significant past medical history.
CASE 3.9 – An elderly woman with aching shoulders and thighs, a painful
temporal headache and a sudden onset of sight loss in her right eye.
A 73-year-old woman describes a 3-week history of stiffness in her proximal arms and thighs, which have become
increasingly painful. The pain is especially bad at night and first thing in the morning. In the last 2 days she has noticed
tenderness in the scalp when combing her hair and headache over the same site. Today she awoke to realize that she had
no sight in her right eye.

OSCE COUNSELLING CASE 3.3 – ‘Will having lupus give me problems should I want
to become pregnant?’
Systemic rheumatological illness 79
Key concepts
The multi-system involvement of this group of conditions, although rare in routine practice, requires all clinicians to
maintain awareness of them. Involvement of systems such as the kidneys and lungs can often be silent in the early stages,
requiring active screening. Many of the differential diagnoses in this group will have similar investigation findings such as a
high CRP and a positive antinuclear antibody (ANA), which can be found in infection and malignancy.
The connective tissue disorders are a group of conditions including rheumatoid arthritis, systemic lupus erythematosus
(SLE), Sjögren’s syndrome, myositis/dermatomyositis, scleroderma and undifferentiated connective tissue disease. Although
recognizably different, they share many features and should be screened for as a group.
The vasculitides are a diverse group of conditions, which can be primary, or secondary in nature. The primary or systemic
vasculitides are usually classified on the basis of the size of the arteries involved:
Large vessel: temporal and Takayasu’s vasculitis
Medium sized: polyarteritis nodosa and Kawasaki’s disease
Small vessel: Wegener’s granulomatosis, Churg–Strauss syndrome, microscopic polyarteritis, Henoch–Schönlein

purpura, essential cryoglobulinaemic vasculitis and leukocytoclastic vasculitis.
Secondary causes include the connective tissue diseases, infection, malignancy and allergy, e.g. drug induced.
80 Rheumatology
Answers
CASE 3.7 – A young woman with joint pains and feeling unwell.
A1
With a symmetrical small and large joint arthritis, a systemic illness including pleurisy and a facial rash, in a woman, SLE
(lupus) is a possible diagnosis. Consider infection, sarcoid, vasculitis and malignancy.
A2
A routine blood screen including FBC, ESR, U&Es and LFTs should be ordered, as well as ANA, double-stranded DNA
(dsDNA) and antibodies to extractable nuclear antigen (ENA). Urinalysis looking for blood or protein should be checked. In
view of the previous chest symptoms a chest radiograph should be ordered.
A3
Finding a positive ANA rarely leads to a diagnosis of lupus. The diagnosis, like much of rheumatology, is clinical and a
specialist opinion usually needs to be sought to confirm it. Often the American College of Rheumatology (ACR) revised
diagnostic criteria are used as a basis to establish the diagnosis, which requires having 4 out of a list of 11 typical features
of the condition. Lupus is also diagnosed by demonstrating typical histological features especially when patients do not
fulfil the ACR.
A4
Once the diagnosis has been confirmed the management depends on the extent of systemic involvement, e.g. active lupus
nephritis will require more aggressive management initially than someone who just has mild arthritis and a rash. Isolated
rash and arthritis can be managed with NSAIDs, hydroxychloroquine and sun block. Systemically ill patients often require
prednisolone, usually combined with immunosuppressive drugs to control their disease.
A5
The management of lupus requires a broad range of clinical skills and may require input from several disciplines. Complex
cases are best managed by clinicians with experience of the condition. Lupus can affect any system in the body and any
new symptoms should be investigated to check for possible lupus involvement. Renal, lung and cardiovascular involvement
need to be regularly screened for. The use of toxic therapies can complicate matters with side effects. There is also an
increased risk of infection as a result of the immunosuppressing nature of SLE and its treatments. In a young woman future
pregnancies may well need careful planning because the disease and drugs may adversely affect fertility. Pregnancy can
impose additional strains on already damaged organs such as the lungs or kidneys.
A6
Spontaneous remission or cure is unlikely. The prognosis of lupus depends on the severity of the condition and is
particularly influenced by the presence of absence of renal disease with only 60 per cent of patients with renal disease
being alive after 15 years.
CASE 3.8 – ‘You’ve seen me before with sinusitis. Now I feel terrible, my eye is
sore and I think I coughed up blood today.’
A1
With renal, upper and lower respiratory symptoms, eye inflammation, myalgia and arthralgia, and blood evidence of
inflammation, systemic vasculitis is probable and in this case Wegener’s granulomatosis is the most likely subtype.
Alternative diagnoses such as malignancy need to be positively ruled out.
A2
Tests should aim to assess the cause, extent and severity of the involvement. FBC, ESR, U&Es and LFTs may all demonstrate
abnormal results. Sinus radiograph, chest radiograph, 24-hour urine protein loss and urine microscopy should also be
performed. ANAs, complements C3, C4 and ANCA (anti-neutrophil cytoplasmic antigen) will help establish the diagnosis.
Specialist ophthalmological and ear, nose and throat (ENT) assessment and treatment may be helpful.
A3
Treatment of vasculitis is long term and typically requires long-term toxic therapy; therefore biopsy is regarded as the gold
standard for diagnosis. The nasal mucosa, lung and kidney are possible sites for biopsy. A positive cANCA/PR3 result is
highly specific and sensitive for Wegener’s granulomatosis.
82 Rheumatology
A4
Having assessed the extent of involvement, treatment typically involves an induction phase designed to arrest inflammation
and a longer-term treatment phase aimed at maintaining disease suppression. Drugs commonly used are steroids,
immunosuppressants and cytotoxics. Co-trimoxazole is prescribed for those patients with Staphylococcus aureus in their
noses, because it is believed to reduce relapses of the condition when used in combination with other
immunosuppressants.
A5
In this patient with renal involvement, potential renal failure needs to be assessed. The lung involvement can progress to
fibrosis. Involvement of the upper airways can produce aggressive local damage, even eroding through the floor of the
anterior skull. Untreated eye involvement can lead to blindness. Secondary infection is a constant threat as a result of the
condition and/or treatment. Flare-ups are not uncommon, often requiring temporary increases in treatment.
A6
A medical cure is not possible. Long-term follow-up with careful multi-system assessment is essential to maximize the
success of treatment. The prognosis is adversely affected by renal involvement; overall the 10-year survival rate is about 80
per cent.
CASE 3. 9 – An elderly woman with aching shoulders and thighs, a painful

temporal headache and a sudden onset of sight loss in her right eye.
A1
The history of polymyalgic symptoms, temporal headache and sudden onset of blindness strongly suggest a diagnosis of
temporal arteritis.
A2
This is a rare example of a rheumatological emergency. Consideration should be given to whether ordering tests will delay
the introduction of prednisolone. After just 48 hours of prednisolone therapy the typical blood findings of a highly raised
ESR and the characteristic biopsy evidence will disappear. However, prompt initiation of steroids may promote return of
vision in the affected eye and should preserve vision in the non-affected eye.
A3
The definitive test is biopsy of an affected temporal artery. As a result of the irregular pattern of vessel involvement, single
biopsy may be falsely negative in up to 30 per cent of cases.
A4
The initial management involves high-dose prednisolone, typically 40 mg/day or more. As treatment will last for more than
3 months, she should be commenced on bone protection therapy with a bisphosphonate and calcium and vitamin D3.
A5
The longer-term management involves reducing the steroids, balancing them against the recurrence of symptoms such as
headache and proximal myalgia and a raised ESR. Most patients will eventually be able to come off steroids. If it is not
possible to reduce the maintenance steroid dose, it may be necessary to commence steroid-sparing drugs such as
azathioprine or methotrexate.
A6
Blindness occurs in up to 15 per cent of patients with this condition. The mortality is not raised compared with a matched
population, even though aortic aneurysm, and cerebral and myocardial infarction are rare complications of this condition.
84 Rheumatology

OSCE COUNSELLING CASE 3.3 – ‘Will having lupus give me problems should I want
to become pregnant?’
Having lupus can affect pregnancy in a number of ways. Overall lupus increases the risk of a conception not progressing to
term from the normal 10 per cent to 25 per cent. Antiphospholipid antibody syndrome increases the risk of miscarriage.
Those women who have Ro and La antibody-associated lupus have an approximately 5 per cent chance of transplacental
spread of antibodies, producing neonatal lupus that can include neonatal heart block. Renal and pulmonary disease can be
complicated by pregnancy. Finally many of the drugs used to treat lupus may adversely affect fertility.
Back pain 85
BACK PAIN

Clinical cases
CASE 3.10 – A sudden onset of back pain in an elderly woman.
A 72-year-old woman describes an acute onset of mid-back pain. She has not had anything like this before and presents to
the accident and emergency department (A&E). There was no obvious precipitant for her back problem. A radiograph
reveals a wedge fracture of T8.
CASE 3.11 – A stiff painful back and a red eye.

An ophthalmologist recommends a 26-year-old man to seek an opinion about his long history of back pain and stiffness
after developing a red and painful left eye.

OSCE COUNSELLING CASE 3.4 – ‘What can I do to prevent osteoporotic fractures in
the future?’
Key concepts
Most adults will suffer back pain at some stage and for many this is a chronic problem. For this group reassurance, active
support and advice to mobilize early and not expect a complete cure are important if disability is to be avoided. Patients
under the age of 25 or over the age of 55 years who present with constant back pain of longer than 6 weeks’ duration
usually require radiological assessment. A history of malignancy, pain that wakes the patient, demonstrable motor
weakness, bowel or bladder involvement and associated systemic involvement suggest significant pathology which may
require more than just a simple radiograph.
86 Rheumatology
Answers
CASE 3.10 – A sudden onset of back pain in an elderly woman.
A1
A spontaneous osteoporotic fracture of the spine is the probable diagnosis. Other causes of a fracture include trauma,
infection and malignancy. Women generally have a lower bone stock than men and with increasing age are prone to
develop osteoporosis. The condition can be secondary to a number of medical conditions, including chronic obstructive
pulmonary disease (COPD), malabsorption, inflammatory arthritis, steroid use, premature menopause, hyperparathyroidism,
hyperthyroidism, chronic renal failure, immobility and autoimmune arthritis.
A2
A history should be taken to look for the above risk factors, as well as for a past history of other low trauma fractures.
Blood testing should be normal in primary osteoporosis but it is important to rule out secondary causes of osteoporosis and
alternative diagnoses.
A3
The gold standard for diagnosis is a dual energy X-ray absorptiometry (DEXA) scan of the lumbar spine and hip. Other
techniques exist, including qualitative computed tomography (QCT), peripheral DEXA scan and ultrasonography of the heel.
A DEXA scan of the spine and hip is best at predicting hip fracture and is sensitive and specific enough to allow monitoring
of therapy. In this case provided that no alternative diagnoses are present, it is not necessary to scan this woman in order
to justify starting medication.
A4
Pain control is the first goal of management. Typically this will require opiate-based treatment and advice about rest. The
pain normally settles progressively over a 12-week period. Calcitonin injections can be used in the first week after a
fracture to augment pain control. The use of transcutaneous electronerve stimulation can augment pain control. Surgery,
although still at an early stage of development, can be used to rebuild the vertebrae and reduce pain.
Back pain 87
A5
The fracture, although painful, rarely produces neurological deficit. The principal risk is that having one osteoporotic
fracture is a strong risk fracture for future fractures. Further vertebral fracture can produce a fixed kyphosis. Fracture of the
hip is the most serious of the osteoporosis-associated fractures; up to one-third may die and only one-third will return to
an independent existence after the fracture. Treatment involves bisphosphonates and usually calcium and vitamin D3.
Further fractures despite appropriate treatment with bisphosphonates may require treatment with teriparatide, a
parathyroid hormone (PTH) analogue.
A6
Treatment of osteoporosis needs to be linked to a falls prevention strategy to maximize the longer-term outlook.
CASE 3.11 – A stiff painful back and a red eye.
A1
The connection to make is iritis and ankylosing spondylitis. It is possible that no connection exists, in which case in a young
person the cause of the back pain could be mechanical, post-traumatic, associated with disc disease or developmental.
A2
A blood screen may demonstrate raised inflammatory markers. A radiograph may demonstrate sclerosis and erosion of the
sacro-iliac joint and squaring of the vertebrae with calcification of the intervertebral ligaments. Magnetic resonance
imaging (MRI) can demonstrate changes not visible on a radiograph. An isotope bone scan can detect inflammation in the
sacroiliac joint or lower back.
A3
Demonstration of the typical radiological changes, although not present in every case, is diagnostic. The presence of the
human leukocyte antigen HLA-B27 gene is not diagnostic because it is found in at least 7 per cent of the general
population. Its absence, however, virtually rules out ankylosing spondylitis.
88 Rheumatology
A4
The principal mode of treatment of mild-to-moderate forms of the disease is physiotherapy. This can be augmented by
NSAIDs; phenylbutazone, banned from general use, still has a place for pain relief in this condition. Methotrexate and
sulphasalazine, although helpful for peripheral disease, do not influence axial disease significantly More aggressive
ankylosing spondylitis not responding to the above measures can be treated with anti-TNF therapies.
A5
The more the spine is involved in ankylosis, the more complications can occur, including the mechanical effects of kyphosis
or ankylosis of the ribs producing respiratory restriction, and a risk of fracture as a result of associated osteoporosis and the
altered mechanics of the stiff spine. It is possible to develop an associated peripheral arthritis as well as psoriasis, iritis,
colitis and inflammation of the genitourinary tract. Rarely, associated cardiac and pulmonary complications can occur.
A6
Long-term surveillance aims to detect early the complications of this chronic illness. An essential part of follow-up also
involves the monitoring of compliance with physiotherapy. The prognosis is adversely affected by age of onset below 16,
early hip involvement, raised CRP and peripheral joint involvement.
Back pain 89

OSCE COUNSELLING CASE 3.4 – ‘What can I do to prevent osteoporotic fractures in
the future?’
About 70 per cent of the risk of developing osteoporosis is genetic; however, a number of factors are important. Lifestyle
measures such as refraining from smoking, keeping alcohol consumption within recommended limits and maintaining a
healthy body mass index (BMI) will be beneficial. Calcium intake equivalent to 800 mg/day is important throughout adult
life. The use of vitamin D3 supplementation in frail elderly individuals is associated with a reduced incidence of hip fractures.
Levels of exercise in childhood and adolescence are one of the determining factors of peak bone mass. In later life regular
exercise will reduce bone loss and decrease the incidence of falls. In elderly, at-risk patients the use of hip protectors also
reduces the incidence of hip fractures. Premature menopause is a risk factor for osteoporosis and the use of hormone
replacement therapy (HRT) does delay the onset of menopausal bone loss until it is stopped. This translates into a lifetime
fracture reduction risk of about 3 per cent. In those with risk factors, a DEXA scan can be used to assess bone density and
appropriate therapy can reduce the risk of future fracture.
4Renal medicine
Indranil Dasgupta
92 Renal medicine
RENAL CASE STUDIES

Q3: How would you manage the case?
Clinical cases
CASE 4.1 – A 58-year-old man presenting with raised serum creatinine.
A 58-year-old South Asian man has recently been found to have a raised serum creatinine of 156 µmol/L (reference range:
60–120 µmol/L). He has been on antihypertensive treatment for 10 years and a smoker for 40 years. He is on nifedipine,
atenolol and simvastatin. His serum creatinine was 121 µmol/L a year ago.
CASE 4.2 – A 22-year-old woman presenting with progressive swelling of legs.

A 22-year-old white woman presented to her GP with progressive swelling of her legs of 2 weeks’ duration. She was
otherwise asymptomatic. On examination, she had oedema up to both knees and her blood pressure (BP) was
120/70 mmHg. Urinalysis revealed +++ proteins but no blood; serum creatinine was 92 µmol/L and serum albumin
1.8 g/dL.
CASE 4.3 – A 34-year-old man presenting with microscopic haematuria.

A 34-year-old man was found to have microscopic haematuria on an insurance medical examination. He was
asymptomatic. His BP was 124/80 mmHg and his serum creatinine 102 µmol/L.
CASE 4.4 – A 62-year-old woman presenting with a raised serum creatinine,

microscopic haematuria and proteinuria.
A 62-year-old woman presented to her GP with symptoms of tiredness, lethargy, aching joints, poor appetite and nausea of
4–6 weeks’ duration. Physical examination was unremarkable except pallor and a BP of 160/100 mmHg. Routine blood
tests revealed: haemoglobin (Hb) 10 g/dL, blood urea 26 mmol/L and serum creatinine 386 µmol/L (glomerular filtration
rate or GFR 14 mL/min). The patient was referred to the local hospital. Further examination revealed purpuric spots in both
legs and +++ blood and +++ protein on urinalysis.
CASE 4.5 – A 76-year-old man presenting with dysuria and nocturia.

A 76-year-old man presented to his GP with a history of difficulty in passing urine in the form of hesitancy, poor stream and
occasional pain while passing urine of 3 months’ duration. He also suffered from nocturia. Physical examination was
unremarkable. Urinalysis showed presence of + for each of blood and protein. Blood test showed a raised serum creatinine
of 560 µmol/L (GFR 11 mL/min). The patient was urgently referred to the nearby district general hospital. Further
examination in the hospital revealed a palpable bladder and a smoothly enlarged prostate on per rectal examination.

OSCE COUNSELLING CASE 4.1 – ‘I have recently been diagnosed as having chronic
kidney disease. What problems can I expect to
have?’
OSCE COUNSELLING CASE 4.2 – ‘As a patient with chronic kidney disease, do I have
a higher risk of heart disease?’
OSCE COUNSELLING CASE 4.3 – ‘As a patient with chronic kidney disease, do I need
to avoid any drugs?’
OSCE COUNSELLING CASE 4.4 – ‘As a patient with kidney failure, do I need to stick
to a diet?’
OSCE COUNSELLING CASE 4.5 – ‘If I need to go on dialysis treatment what are the
treatment options?’
Key concepts
Common causes of end-stage renal failure
Diabetes is the most common cause of end-stage renal failure (ESRF) accounting for about 20 per cent of cases in England
and Wales (nearly 50 per cent in the USA). The other main causes are glomerulonephritis (10 per cent), pyelonephritis (6.5
per cent), renovascular disease (7 per cent), hypertension (6 per cent) and adult polycystic kidney disease (PCK) (6 per cent)
(Ansell D, Feest T, eds (2003) UK Renal Registry Report. Bristol: UK Renal Registry). In a good number of patients (nearly a
quarter of patients in England and Wales), the aetiology is uncertain because these patients present late when it is difficult
to establish a primary renal diagnosis.
Formulae for calculating creatinine clearance and GFR

Cockroft–Gault formula or creatinine clearance (mL/min):
Males: = [1.23 × (140 − Age) × Weight]/[Creatinine].
Females: [1.04 × (140 − Age) × Weight]/[Creatinine].

94 Renal medicine
MDRD formula (abbreviated form: GFR in mL/min per 1.73 m2:

Males: GFR = 186 × ([Creatinine]/88.4)−1.154 × Age−0.203.
Females: GFR = 138 × ([Creatinine]/88.4)−1.154 × Age−0.203.
Multiply by 1.21 if the patient is African–Caribbean.
The MDRD formula is derived from Modification of Diet in Renal Disease study results.
1000
900
Serum creatinine (µmol /L)
800
700
600
500
400
300
200
100
0
0 10 20 30 40 50 60 70 80 90 100 110 120
GFR (inulin clearance, ml/min per 1.73m2)
Figure 4.1 Relationship between serum creatinine and glomerular filtration rate (GFR). Serum
creatinine remains normal until the GFR is around 60 mL/min.
Table 4.1 Stages of chronic kidney disease – NKF K/DOQIa classification
Stage GFR (mL/min per 1.73 m2) Description
1 ≥ 90 Kidney damage with normal or high GFR
2 60–89 Mild
3 59–30 Moderate
4 29–15 Severe
5 < 15 End-stage kidney failure or on dialysis

a
National Kidney Foundation, Kidney Disease Outcomes Quality Initiative.
GFR, glomerular filtration rate.
Reproduced with kind permission from the National Kidney Foundation (2002). K/DOQI Clinical Practice
Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. Ann J Kidney Dis 39:
19.
Answers
CASE 4.1 – A 58-year-old man presenting with raised serum creatinine.
A1
Chronic renal failure (CRF) – although this patient’s serum creatinine was just outside the normal range a year ago, his
calculated GFR using the MDRD formula was 57 mL/min and his current GFR is 40 mL/min. Serum creatinine is not a
reliable test to assess renal function because it is influenced by a number of factors including age, muscle mass, renal
tubular secretion and extrarenal loss of creatinine. A number of regression equations, which can predict GFR/creatinine
clearance, are available and, of these, the Cockroft–Gault and MDRD are most commonly used.
The cause of CRF, in this case, is uncertain pending further investigations, although hypertensive nephrosclerosis is a
possibility.
A2
Urinalysis, full blood count (FBC), serum calcium and phosphate, immunology and renal ultrasonography would be the
initial investigations. A low Hb, high serum phosphate and bilateral small kidneys on ultrasonography will support the
diagnosis. Normal sized kidneys with significant microscopic haematuria and proteinuria, with or without a positive
immunological test, will indicate the need for a renal biopsy to establish an underlying cause of the CRF.
A3
This patient suffers from moderate chronic kidney disease (CKD stage 3). Hypertension and proteinuria are the two most
important progression promoters. Aggressive BP control is the most important measure to prevent/slow down progression
of renal disease to ESRF. Target BP should be 130/80 mmHg. In patients with proteinuria > 1 g/ day, the target BP should
be 125/75 mmHg. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers reduce proteinuria,
and have been shown to retard progression of renal disease. These patients are also at very high cardiovascular risk. They
should be urged to stop smoking, lose weight if obese and be treated for hyperlipidaemia. Patient should also be advised
to avoid non-steroidal anti-inflammatory and other nephrotoxic drugs.
A4
Chronic kidney disease in this patient is likely to progress to ESRF requiring dialysis or renal transplantation. Patients with
CKD stage 3 have a significantly increased risk of cardiovascular morbidity and mortality.
96 Renal medicine
CASE 4.2 – A 22-year-old woman presenting with progressive swelling of legs.
A1
Nephrotic syndrome – defined as the presence of oedema, heavy proteinuria (> 3 g/day) and hypoalbuminaemia with or
without hypercholesterolaemia and hypertension.
The most common cause of nephrotic syndrome is minimal change nephropathy, especially in children. In adults,
membranous nephropathy and focal segmental glomerulosclerosis (FSGS) are also common causes of nephrotic syndrome.
In as many as 30 per cent of cases nephrotic syndrome is the result of a systemic disease such as diabetes mellitus,
systemic lupus erythematosus (SLE), amyloidosis, multiple myeloma.
A2
Refer to a nephrologist for a renal biopsy. Blood sugar and lipids should be checked. Blood should be sent off for
immunological tests such as antinuclear antibodies, complements, serum immunoglobulins and cryoglobulins.
A3
Management depends on renal biopsy finding. Minimal change disease is treated with high-dose prednisolone (1 mg/kg,
maximum 80 mg/day). This is continued until 1 week after remission (may take up to 16 weeks). The dose is then reduced
gradually with a view to stop between 8 and 12 weeks. FSGS sometimes responds to a prolonged course of corticosteroids.
Oedema is treated with salt restriction and loop diuretics. Severely nephrotic patients are treated with heparin while they
are admitted to hospital to prevent venous thromboembolism. ACE inhibitors are often used to treat hypertension and
reduce proteinuria. Hypercholesterolaemia should be treated with a statin.
A4
Minimal change nephrotic syndrome in children responds promptly to high-dose corticosteroid therapy. In adults, it does
not always respond to corticosteroids as quickly and often relapses. Membranous nephropathy spontaneously remits in up
to 25 per cent of patients and progresses to ESRF in about 40 per cent of patients at 15 years. FSGS leads to ESRF in about
50 per cent of cases and often recurs after transplantation.
CASE 4.3 – A 34-year-old man presenting with microscopic haematuria.
A1
Isolated microscopic haematuria – the most common causes of this in young people are IgA nephropathy and thin
basement membrane disease. IgA nephropathy is the most common form of glomerulonephritis characterized by deposition
of IgA in the mesangium. Thin basement membrane disease is a familial condition, which is characterized by uniform
thinning of the glomerular basement membrane. The other causes of microscopic haematuria are stones, cystic diseases of
kidney, tumour and inflammatory diseases of the urinary tract. Urological causes predominate in older patients.
A2
Urinalysis needs to be repeated, because transient microscopic haematuria may not be significant. Moreover, presence of
significant proteinuria (++ or more) may signify a more aggressive form of glomerulonephritis. Ideally, urine should be sent
for microscopy to ensure there are two or more red blood cells (RBCs) per high power field. Dipsticks are very sensitive and
often detect less significant haematuria, Hb and myoglobin. Ultrasonography of the kidneys and urinary tracts should be
done to exclude a macroscopic pathology. Serum immunoglobulins, complements, autoantibodies and ANCA (anti-
neutrophil cytoplasmic antigen) should be checked. A raised serum IgA level will support a diagnosis of IgA nephropathy.
Normal autoantibody, complement and ANCA tests will make an underlying autoimmune disease or vasculitis unlikely. If
there is significant proteinuria (> 1 g/day) a renal biopsy will be indicated to exclude acute glomerulonephritis.
A3
No specific treatment is indicated. The patient should be followed on a regular basis – perhaps annually – for measurement
of BP, urinalysis and serum creatinine. Should the patient develop significant proteinuria or there is a rise in serum
creatinine, renal biopsy should be considered. If the patient develops hypertension, it should be treated, preferably with an
ACE inhibitor.
A4
Prognosis is good. IgA nephropathy rarely progresses to advanced renal failure in the absence of significant proteinuria,
hypertension and/ or raised serum creatinine at presentation. Thin basement membrane disease rarely causes proteinuria,
renal impairment or hypertension.
98 Renal medicine
CASE 4.4 – A 62-year-old woman presenting with a raised serum creatinine,

microscopic haematuria and proteinuria.
A1
Acute glomerulonephritis, possibly associated with systemic vasculitis.
A2
Urine microscopy – presence of RBC casts – will support the diagnosis of acute glomerulonephritis. Send off blood for
immunological tests such as ANCA, anti-GBM (glomerular basement membrane) antibodies, antinuclear antibodies (ANAs),
immunoglobulins and complements. A positive ANCA test will support a diagnosis of systemic vasculitis (cytoplasmic or
cANCA is associated with Wegener’s granulomatosis and perinuclear or pANCA with microscopic polyangiitis). A positive
ANA (especially anti-double-stranded [anti-dsDNA]) with low complements will support a diagnosis of lupus nephritis.
Raised anti-GBM antibody titre will raise the suspicion of Goodpasture’s disease. Chest radiograph should be performed to
look for consolidation, cavitation or pulmonary haemorrhage, which supports a diagnosis of either systemic vasculitis or
anti-GBM disease. Ultrasonography of kidneys. Renal biopsy will confirm the diagnosis of acute glomerulonephritis.
A3
Immunosuppressive treatment is initiated after confirmation of diagnosis by a renal biopsy. However, if the patient is too ill
to biopsy, a presumptive diagnosis is made based on clinical features and positive ANCA test. The standard
immunosuppressive regimen consists of oral prednisolone (1 mg/kg per day, maximum 80 mg/day) and cyclophosphamide
(2 mg/kg per day). Intravenous pulsed methylprednisolone and/or plasma exchange is used for induction of remission in
patients with aggressive (life- or organ-threatening) disease. After 2 weeks, the dose of prednisolone is reduced gradually
to 15 mg at 3 months and 10 mg at 6 months. To minimize side effects with prolonged use, cyclophosphamide is changed
after 3 months to azathioprine for maintenance treatment. In view of the risk of relapse (30–50 per cent at 3–5 years),
maintenance treatment using small doses of prednisolone and azathioprine is often continued long term.
A4
Untreated systemic vasculitis is associated with high mortality rate (90 per cent at 2 years). Immunosuppressive treatment,
as described above, leads to control of disease in 80–90 per cent of patients. Pulmonary haemorrhage and dialysis
dependence at presentation are poor prognostic features. As a rule, patients who require dialysis treatment at presentation
are less likely to have significant improvement in their kidney function.
CASE 4.5 – A 76-year-old man presenting with dysuria and nocturia.
A1
Acute or acute-on-chronic renal impairment resulting from bladder neck obstruction by an enlarged prostate.
A2
Urinary catheterization: a large residual volume of urine would confirm the diagnosis of urinary retention caused by
bladder neck obstruction. Ultrasonography of the abdomen and pelvis would reveal bilateral hydronephrosis,
hydroureter and an enlarged prostate. Bilateral small kidneys or cortical thinning would suggest that the obstruction
(chronic retention) is long standing.
Serum prostate-specific antigen (PSA) assay: a high serum concentration would suggest possible prostatic malignancy
(caution: sample taken after per rectal examination/catheterization may show a spuriously high level).
A3
Immediate bladder catheterization should be done to relieve obstruction. If catheterization is difficult, the urology team
should be informed, because suprapubic catheterization may be required. Fluid balance (intake and output) should be
monitored, because the patient is likely to have a large diuresis. Urea and electrolytes should also be monitored daily. If the
patient is unable to drink a large amount of fluid to keep up with the urine output, intravenous fluid – 0.9 per cent saline
with or without potassium chloride depending on serum potassium level – should be infused. When the renal function
stabilizes, the urology team should be involved for long-term management of prostatic enlargement. Occasionally, bilateral
nephrostomy drainage is required if there is no significant diuresis after bladder catheterization and/or no significant
improvement in hydronephrosis on repeat ultrasonography.
A4
This depends on the chronicity of urinary obstruction. In most cases, renal function improves significantly and remains
stable for many years. In patients who have long-standing chronic obstruction, especially those who have very thin renal
cortex on ultrasonography, renal function may not improve at all. These patients go on to need dialysis treatment.
100 Renal medicine

OSCE COUNSELLING CASE 4.1 – ‘I have recently been diagnosed as having chronic
kidney disease. What problems can I expect to
have?’
Mild or moderate CKD (GFR > 30 mL/min) does not generally cause any symptoms. In severe CKD (GFR < 30 mL/min),
common symptoms are tiredness and generalized itching. As dialysis approaches, patients develop anorexia, nausea and
vomiting. These ‘uraemic symptoms’ are the result of progressive accumulation of waste products (uraemic toxins) and
anaemia.
The following are the common complications of CKD.
ANAEMIA
It results mainly from a low concentration erythropoietin. The other factors that contribute to anaemia in CKD are
functional iron deficiency, anaemia of chronic disease, upper gastrointestinal (GI) blood loss and direct suppression of bone
marrow by the waste products. The patient is treated with erythropoietin injection when Hb drops below 11 g/dL provided
there is no iron deficiency.
SALT AND FLUID RETENTION

This leads to oedema, hypertension and, in severe cases, pulmonary oedema. The patients are advised to restrict salt and
fluid intake, and treated with loop diuretics.
HYPERTENSION
This is common and strict BP control is needed to slow down or prevent deterioration of kidney function. The target BP is
130/80 mmHg. The ACE inhibitors and angiotensin receptor blockers are particularly beneficial in terms of protection of
renal function.
RENAL BONE DISEASE OR OSTEODYSTROPHY

This is not a single entity. It comprises secondary hyperparathyroidism, adynamic bone disease (resulting from low bone
turnover), osteomalacia or a combination of these. Phosphate retention and diminished production of active vitamin D
(caused by impaired 1α-hydroxylation) are the initiating events. The patients are advised to follow a low-phosphate diet
from an early stage and put on phosphate binders such as calcium carbonate and acetate. They are also treated with α-
hydroxylated vitamin D (such as alfacalcidol) if their serum parathyroid hormone (PTH) concentration is high.
CARDIOVASCULAR DISEASE
Patients with CKD have a very high risk of heart disease and strokes. This is discussed in detail on page 101.
MALNUTRITION
This occurs as a result of a combination of anorexia with nausea/vomiting in the later stages of CKD and dietary restrictions
imposed to tackle high serum phosphate and potassium. Most renal units employ dietitians who advise these patients
regularly.
INFECTIONS
These are common because of reduced immunity as a result of a combination of impaired T-cell and neutrophil functions.
The patients are immunized with hepatitis B vaccine at an early stage. It is also recommended that they have influenza
immunization annually and pneumococcal vaccination 5-yearly.
OSCE COUNSELLING CASE 4.2 – ‘As a patient with chronic kidney disease, do I have
a higher risk of heart disease?’
Chronic kidney disease is associated with high cardiovascular risk. Patients with CKD have up to three fold risk of suffering
cardiovascular events and death. Patients with ESRF who are on dialysis have even higher cardiovascular risk. Death as a
result of cardiovascular disease is 10–20 times higher in dialysis patients compared with the general population.
Apart from the classic risk factors such as hypertension, hyperlipidaemia and smoking, these patients also have left
ventricular hypertrophy, chronic anaemia, abnormal apolipoproteins, raised serum phosphate (with or without high calcium
phosphate product), arterial calcification, elevated plasma homocysteine level, enhanced coagulability and abnormal
endothelial function. All of these probably contribute towards their extremely high cardiovascular morbidity and mortality. It
is, therefore, important to treat their blood pressure aggressively, urge them to stop smoking, and put them on aspirin and
statin. The serum phosphate level is generally controlled with dietary restriction and the use of phosphate binders. Anaemia
should be treated early and effectively with erythropoietin.
OSCE COUNSELLING CASE 4.3 – ‘As a patient with chronic kidney disease, do I need
to avoid any drugs?’
A variety of insults, which would have little impact on healthy kidneys, may cause significant loss of renal function in
patients with pre-existing kidney damage. When more than one nephrotoxic factor is present, the risk of worsening renal
function is much increased. Apart from renal disease itself, important predisposing factors include:
Old age: GFR falls by 50 per cent by 80 years of age as a result of normal ageing processes
Diabetes
Atherosclerosis: peripheral vascular disease often involves the renal arteries too
Cardiac failure: low cardiac output leads to ‘pre-renal’ uraemia
Hypovolaemia
Hepatic failure: associated with renal vasoconstriction and ‘pre-renal’ uraemia
Myeloma: with or without hypercalcaemia or hyperuricaemia
Transplant kidney: vulnerable even with a normal creatinine.
COMMON NEPHROTOXIC AGENTS

ACE inhibitors and angiotensin receptor blockers: reduce GFR in renal arterial stenosis (RAS) and sometimes in chronic
renal failure. Do not use if RAS is likely. Captopril is shorter acting and so more quickly reversible. Beware a major drop
in BP in volume-depleted patients. Check creatinine before and 3–7 days after starting treatment. Watch K+ also.
Non-steroidal anti-inflammatory drugs (NSAIDs): reduce the vasodilatory effect of prostaglandins and lead to
unopposed vasoconstriction.
102 Renal medicine
Aminoglycosides: trough and peak levels should be measured. The nephrotoxic effect may also be related to the total
cumulative dose received.
Ciclosporin: a dose-related NSAID-like effect.
Radiological contrast: protection of GFR with adequate hydration pre-study is essential.
Tetracyclines: doxycycline is metabolized in the liver and is the only safe one.
OSCE COUNSELLING CASE 4.4 – ‘As a patient with kidney failure, do I need to stick
to a diet?’
Most renal units have specialist renal dietitians attached to the unit. They advise patients regularly about their dietary and
fluid restrictions. Patients with CRF need to restrict their phosphate intake at an early stage; recent guidelines suggest
phosphate restriction when GFR drops to < 60 mL/min. Phosphate is found in almost all foods, but is especially high in
milk and milk products, liver, dried beans and nuts. Dialysis does not clear phosphate very effectively and, therefore, the
patient needs to continue on a low-phosphate diet even when on dialysis. Patients are also asked to restrict their
potassium intake. Major sources of potassium are fruits (especially citrus fruits and bananas), vegetables, chocolate, coffee
and salt substitutes. Salt restriction is recommended to help BP control and fluid retention even when the patient is on
dialysis. Patients are advised to restrict their total fluid intake to about a litre a day unless they have a significant urine
output.
OSCE COUNSELLING CASE 4.5 – ‘If I need to go on dialysis treatment what are the
treatment options?’
Renal replacement therapy (RRT) is generally required when the GFR is around 10 mL/min (ESRF). Most patients with CRF
are symptomatic (with anorexia, nausea and vomiting) at this stage. Some advocate earlier start but, as yet, there is no
convincing evidence to suggest a survival benefit of early commencement of dialysis. Patients with diabetes often become
symptomatic at an earlier stage and start dialysis with a higher GFR compared with patients who do not have diabetes.
Some CRF patients start dialysis as an emergency because of either intractable hyperkalaemia or severe pulmonary
oedema.
There are three modalities of RRT:
1. Haemodialysis
2. Peritoneal dialysis – either continuous ambulatory (CAPD) or automated (APD)
3. Renal transplantation.
The optimal choice of modality of RRT depends on the patient’s age, functional capacity, co-morbidities, family support and,
above all, patient’s choice. Some patients receive all three at various stages of their illness. Some patients, who have
chosen not to have dialysis treatment or are deemed unlikely to benefit from it, are treated conservatively with full
supportive treatment including erythropoietin therapy.
The annual acceptance rate and prevalence of RRT in the UK are 101 and 626 per million population respectively. Forty-six
per cent of prevalent patients have a functioning transplant and 73 per cent of the dialysis patients are on haemodialysis
(Ansell D, Feest T, eds (2003) UK Renal Registry Report. Bristol: UK Renal Registry).
RENAL EMERGENCIES

Q4: What would be the long-term management?
Clinical cases
CASE 4.6 – A 60-year-old man presented with diarrhoea, vomiting and renal
impairment.
A 60-year-old man, previously fit and well, presented to the accident and emergency department (A&E) with a 1-week
history of diarrhoea and vomiting. He was unwell and clammy, his skin turgor was poor, and his pulse and BP were
120/min and 80/60 mmHg, respectively. Initial investigations showed serum Na+ 126 mmol/L, K+ 3.0 mmol/L, urea 28
mmol/L and creatinine 306 µmol/L (calculated GFR 22.5 mL/min).
CASE 4.7 – A 72-year-old man presenting with hyperkalaemia.

A 72-year-old man has been referred by the GP to A&E with a history of being non-specifically unwell for 2 days. He has a
past history of ischaemic heart disease, atrial fibrillation, congestive cardiac failure and stable CRF. His regular medications
include isosorbide mononitrate, digoxin, furosemide, spironolactone and an ACE inhibitor. On examination the patient is
mildly confused, dehydrated, peripherally cold, bradycardic and hypotensive (BP 96/60 mmHg). His initial blood tests show
Na+ 130 mmol/L, K+ 7.2 mmol/L, urea 42 mmol/L and creatinine of 412 µmol/L (GFR 14 mL/min).
CASE 4.8 – A 68-year-old woman with CRF presenting with shortness of breath.
A 68-year-old woman, a known CRF patient, has presented to A&E with acute shortness of breath. Computer records
suggest that her most recent serum creatinine from about a month earlier was 256 µmol/L (GFR 21 mL/min) and her
regular medication includes furosemide 80 mg daily. She has recently been commenced on an NSAID for arthritis. On
examination, she has oedema up to her mid-thighs, her jugular venous pressure (JVP) is raised at 6 cm, and there are
crackles in both lung bases up to the midzones. Her admission ECG does not show any ischaemic changes, and her urea
and electrolytes (U&Es) show: Na+ 138 mmol/L, K+ 5.6 mmol/L, urea 38 mmol/L, creatinine 446 µmol/L (GFR 12 mL/min).
CASE 4.9 – A 34-year-old man presenting with severe hypertension and renal
impairment.
A 34-year-old man of African–Caribbean origin has been referred by his GP for severe hypertension. On examination, his
BP is 240/140 mmHg, he is slightly confused, there is mild pedal oedema, there are a few basal crackles and neurological
examination is normal except for bilateral papilloedema. Urine analysis shows blood ++, protein ++. His Hb is 10.2 g/dL
and U&Es show Na+ 136 mmol/L, K+ 3.0 mmol/L, urea 14 mmol/L and creatinine 206 µmol/L (GFR 54 mL/min).
104 Renal medicine
Key concepts
Common causes of acute renal failure (ARF)
Pre-renal
As a result of ineffective perfusion of kidneys that are structurally normal
Hypovolaemia: blood loss, GI loss, burns
Low cardiac output states
Shock
Certain drugs: NSAIDs, ACE inhibitors
Renal
Structural damage to glomeruli and tubules
Acute tubular necrosis (ATN): most common cause (45 per cent), results from prolonged hypoperfusion due to
hypovolaemia (as above)
Acute glomerulonephritis and vasculitis
Acute interstitial nephritis: idiopathic, drugs, infection
Vascular disease
Post-renal
As a result of urinary tract obstruction
Prostatic hypertrophy
Bladder tumour
Gynaecological malignancy
Neuropathic bladder.
Investigations to organize in ARF
Urine
Dipstick (blood and protein suggest acute glomerulonephritis), microscopy (RBC casts diagnostic of acute
glomerulonephritis), urine electrolytes (to distinguish pre-renal from ATN)
Blood
FBC, clotting: for disseminated intravascular coagulation (DIC), rarely haemolytic uraemic syndrome/TTP (thrombotic
thrombocytopenic purpura)
U&Es, Ca2+ and phosphate, glucose, creatine kinase (for rhabdomyolysis), CRP (for vascultis, sepsis)
Immunology: autoantibodies (for SLE), ANCA (for vascultis), anti-GBM antibodies (for Goodpasture’s syndrome),
complements (low in SLE, infective endocarditis), immunoglobulins (for IgA nephropathy, myeloma)
Blood cultures (sepsis, infective endocarditis), hepatitis B and C (in preparation for dialysis)
ECG: for hyperkalaemic changes
Chest radiograph: for pulmonary oedema, pneumonia
Ultrasonography: to exclude obstruction.
Indications for urgent dialysis in ARF
Severe hyperkalaemia (> 6.5 mmol/L or less with ECG changes, despite medical treatment)
Pulmonary oedema
Severe acidosis (pH < 7.1)
Severe uraemia (vomiting, encephalopathy)
Uraemic pericarditis
Overall mortality rate in ARF is about 50 per cent (up to 80 per cent in patients who require dialysis).
106 Renal medicine
Answers
CASE 4.6 – A 60-year-old man presented with diarrhoea, vomiting and renal
impairment.
A1
Pre-renal failure or ATN resulting from reduced circulatory blood volume secondary to diarrhoea and vomiting. Loss of
circulatory volume, caused by either salt and water depletion or haemorrhage, leads to reduced renal blood supply. This
results in selective cortical vasoconstriction and oliguria (urine output < 400 mL/day). Initially this is reversible but when
prolonged leads to ATN (ischaemic injury to the proximal tubular epithelial cells) and rarely to acute cortical necrosis
A2
Urinalysis (dipstick test for blood and protein), urine microscopy, U&Es, FBC, serum bicarbonate, calcium and phosphate.
Presence of significant amount of blood and protein (++ or more) in urine would raise a suspicion of acute
glomerulonephritis. Urine Na+ concentration of < 20 mmol/L would suggest reversible pre-renal failure, whereas
> 40 mmol/L would suggest that ATN has set in. Low Hb and/ or a raised serum phosphate may indicate the presence of
pre-existing chronic renal impairment.
A3
Intravenous access and intravenous infusion should be set up immediately. The ideal fluid replacement in this setting would
be 0.9 per cent saline with potassium supplementation. In the presence of severe metabolic acidosis, sodium bicarbonate
(1.26 per cent) infusion should be considered. It is preferable to remove the patient to a high dependency unit with a view
to establishing central venous access to monitor central venous pressure (CVP). Pulse, BP and urine output should be
monitored hourly. In the absence of CVP monitoring, lung bases should be auscultated frequently to prevent over-hydration
leading to pulmonary oedema. Urea and electrolytes should be repeated in 4–6 hours to review progress.
A4
Pre-renal failure is a rapidly reversible condition. In established ARF caused by ATN, it may take as long as 6 weeks for renal
function to return to normal and the patient will require dialysis treatment for this period (1 per cent require long-term
dialysis). If the patient is haemodynamically compromised, an initial period of continuous veno-venous haemofiltration
(CVVH) may be necessary (generally in the intensive care unit [ICU]). If renal function does not improve within 24 hours,
ultrasonography should be requested to exclude urinary tract obstruction. Small shrunken kidneys on ultrasonography
would suggest that the patient has CRF.
CASE 4.7 – A 72-year-old man presenting with hyperkalaemia.
A1
Severe hyperkalaemia as a result of a combination of a potassium-sparing diuretic and an ACE inhibitor in the setting of
chronic renal impairment. There is also a possible acute-on-chronic renal impairment caused by over-diuresis, as evidenced
by a disproportionately high blood urea level and low Na+.
A2
A 12-lead ECG to see if there are any changes of hyperkalaemia – tall, peaked T waves, widening of QRS, reduction in
height of P (may disappear) and R waves, sine wave pattern (pre-cardiac arrest).
A3
Severe hyperkalaemia (> 6.5 mmol/L) and the presence of ECG changes in this scenario warrant urgent treatment of
hyperkalaemia as follows:
Calcium gluconate: 10 mL 10 per cent i.v. over 5 min to counteract the adverse effect of hyperkalaemia on the cardiac
conduction system (through a central line or a large cannula in a big vein to avoid delay).
Infusion of 10 U insulin in 50 mL 50 per cent glucose i.v. through a pump over 30 min to drive K+ into intracellular
space.
Nebulized salbutamol: 5 mg to help K+ enter intracellular space.
Sodium bicarbonate: 8.4 per cent 50 mL i.v. over 30 min – should be considered especially if acidotic (caution: may
precipitate tetany if the serum Ca2+ is low).
Calcium resonium 30 g rectally or 15 g orally to help exchange K+ for Ca2+ in the gut.
To check U&Es in 2 h and repeat glucose and insulin infusion and nebulized salbutamol if serum K+ remains
dangerously high (> 6.5 mmol/L) or ECG changes persist.
If serum K+ continues to remain > 6.5 mmol/mL or ECG changes persist despite treatment, haemodialysis may be
required.
Intravenous infusion of 0.9 per cent saline to correct dehydration.

108 Renal medicine
A4
The ACE inhibitor and spironolactone must be stopped. Refer the patient to the nephrologist for long-term management. If
renal function returns to near the baseline, the ACE inhibitor may be restarted cautiously in the future if clinically indicated,
i.e. poor left ventricular function on echocardiography. The patient should be followed up closely, preferably in the renal
clinic.
CASE 4.8 – A 68-year-old woman with CRF presenting with shortness of breath.
A1
This patient’s severe shortness of breath is likely to be caused by pulmonary oedema secondary to severe fluid retention.
Acute deterioration in renal function has probably been precipitated by the recent introduction of an NSAID. NSAIDs reduce
renal blood flow in patients with pre-existing renal disease and, thereby, cause deterioration of renal function. They can
also cause acute interstitial nephritis leading to acute renal impairment.
A2
Chest radiograph to confirm the diagnosis of pulmonary oedema (Figure 4.2). Arterial blood gas (ABG) analysis should be
done to assess the degree of hypoxia, to ascertain whether there is any evidence of CO2 retention and assess the degree of
metabolic acidosis associated with renal failure.
Figure 4.2 Chest radiograph for Case 4.8.
(This ‘real’ patient had a positive cANCA test and the renal biopsy showed the presence of acute necrotizing crescentic
glomerulonephritis.)
A3
Furosemide 80 mg i.v. If there is no significant diuresis, furosemide should be repeated using a higher dose (up to 250 mg
i.v.). High-concentration oxygen should be given with a facemask. It may be necessary to use CPAP (continuous positive
airway pressure) or even to ventilate the patient in the ITU if the patient is severely hypoxic. If the patient remains severely
short of breath and oligo-anuric despite high-dose intravenous furosemide, the patient will need to be referred for urgent
haemodialysis or haemofiltration.
A4
Long-term management will depend on whether her renal function returns to baseline/near baseline after stopping the
NSAID. If renal function improves, long-term management will consist of salt and fluid restriction, high-dose oral diuretic
therapy and avoidance of nephrotoxic agents. The patient will need to be prepared for dialysis treatment. On the other
hand, if her renal function fails to improve, she will require acute dialysis leading to long-term dialysis treatment.
CASE 4.9 – A 34-year-old man presenting with severe hypertension and renal
impairment.
A1
Malignant hypertension, which is defined as severe hypertension, often > 200/140 mmHg; this is associated with
papilloedema, usually accompanied by retinal haemorrhage and exudates, with or without renal impairment or
neurological symptoms. It most commonly occurs in patients with long-standing uncontrolled hypertension. Differential
diagnosis of this case scenario would be acute glomerulonephritis with severe hypertension.
A2
A chest radiograph must be done to confirm or exclude pulmonary oedema. If confusion persists/deteriorates (deteriorating
Glasgow Coma Score [GCS]), urgent computed tomography (CT) of the brain should be organized to exclude infarction or
haemorrhage.
110 Renal medicine
A3
Controlled lowering of blood pressure should be attempted with intravenous infusion of labetalol (a combined α- and β-
adrenergic blocker) or sodium nitroprusside (a combined arteriolar and venodilator). The goal is to lower diastolic BP to
between 100 and 105 mmHg, with systolic pressure around 160 mmHg, over 2–6 hours. Rapid lowering of BP may lead to
cerebral vasospasm, resulting in cerebral infarction. The patient should ideally be treated in a high-dependency unit. If
parenteral antihypertensive agents are not available, oral agents may be used but their use (especially sublingual
nifedipine) is associated with the risk of causing excessive lowering of BP, leading to stroke or myocardial infarction.
A4
Once the BP is controlled, the patient should be switched to oral antihypertensive therapy with gradual reduction of
diastolic BP to 85–90 mmHg over 2–3 months. The patient should be investigated for a secondary cause of hypertension.
Renal biopsy is indicated if renal function fails to stabilize with BP control. Long-term follow-up is needed for careful
monitoring of renal function and strict control of BP because renal function may deteriorate progressively to ESRF.
5Cardiology
Nevianna Tomson and Neeraj Prasad
112 Cardiology

Q2: What is the most likely diagnosis?
Q6: What other issues should be addressed?
Clinical cases
CASE 5.1 – A 34-year-woman with palpitations.
A 34-year-old woman presented with a 3-hour history of palpitations. She is mildly dyspnoeic and has some chest pain. She
has been feeling anxious and suffering from insomnia for the last few weeks. On direct questioning she admits to a 10-day
history of diarrhoea. On examination she has a tachycardia and her pulse is irregular.
CASE 5.2 – A 53-year-old man with sudden onset of chest pain.

A 53-year-old man is brought into the accident and emergency department (A&E) by ambulance complaining of sudden
onset of severe central chest pain. He is cold and clammy, and appears breathless.
CASE 5.3 – An 80-year-old patient collapses, requiring cardiopulmonary

resuscitation (CPR).
A 80-year-old woman collapsed at home and has been brought into A&E unconscious. She was given basic life support at
home by her daughter who happens to work as a ward sister on coronary care. The paramedics are performing CPR as the
patient is wheeled into A&E accompanied by her tearful daughter.
CASE 5.4 – A 65-year-old man with tearing chest pain.

A 65-year-old man was brought into A&E complaining of severe tearing pain between the shoulder blades. Initially the pain
was extremely severe but has now mildly subsided to a dull ache in the chest. He is normally fit and well apart from
hypertension, for which he has been seeing the GP.
CASE 5.5 – A 25-year-old man with a heart murmur.

A 25-year-old man recently attended a medical in the process of getting into the police force. He has been told that he has
a heart murmur.
Key concepts 113

OSCE COUNSELLING CASE 5.1 – ‘Can I stop my warfarin (anticoagulation in a
patient with prosthetic heart valve)?’
A 24-year-old woman had a metal prosthetic heart valve inserted 4 years ago after a severe episode of bacterial
endocarditis that degenerated her mitral valve. She has done very well since the surgery and has been on warfarin,
regularly attending an anticoagulation clinic. She has come to see you today because she wants to have a family but has
read on the internet that warfarin can damage the baby. Can she stop her warfarin?
OSCE COUNSELLING CASE 5.2 – The use of anti-anginal medication.

This 73-year-old man has recently been diagnosed with angina. He is able to walk 300 metres before experiencing chest
tightness, but considerably less when there is an incline. His recent exercise stress test has indicated ischaemic heart
disease (IHD) and he has been prescribed sublingual GTN (glyceryl trinitrate) tablets and a β-adrenoreceptor blocker. Please
advise him on how to use the medication and explain any side effects of which he should be aware.
OSCE COUNSELLING CASE 5.3 – ‘I have heart failure. Do I need to take my

medications for life?’
A 65-year-old man with known IHD, hypertension and diabetes mellitus has recently been complaining of shortness of
breath. An echocardiogram has confirmed left ventricular (LV) systolic dysfunction, which is moderately severe, and he has
been started on ramipril 10 mg once daily, bisoprolol 2.5 mg once daily and spironolactone 25 mg once daily. He is very
concerned about the number of medications that he is now on because these are additional to his other therapies. Explain
the importance of his diagnosis and treatments to him.
Key concepts
Benefits of drug management in chronic heart failure

Diuretics: loop diuretics and thiazide diuretics improve symptoms of congestion.
Spironolactone 25–50 mg once daily improves survival in severe (New York Heart Association [NYHA] stage III/IV)
heart failure
Angiotensin-converting enzyme (ACE) inhibitors: improved symptoms, exercise capacity and survival in patients with
asymptomatic and symptomatic systolic dysfunction.
– lisinopril 2.5 mg initial dose, 20 mg once daily target dose, sometimes up to 30 mg once daily
– ramipril 1.25–2.5 mg initial dose, 10 mg once daily target dose
– captopril* 6.25 mg initial dose, 50 mg three times daily target dose.

114 Cardiology
Angiotensin II antagonists: treatment of symptomatic heart failure in patients intolerant to ACE inhibitors:*
– losartan and valsartan
β Blockers: improved symptoms and survival in stable patients who are already receiving ACE inhibitor with LV systolic
dysfunction
– Bisoprolol (Cardicor) 1.25 mg once daily titrated with close monitoring to 10 mg once daily.
– Carvedilol 3.125 mg twice daily increasing to with close monitoring 25–50 mg twice daily.
Digoxin: improved symptoms, exercise capacity and fewer admissions to hospital.
Nitrates and hydralazine: improved survival in symptomatic patients intolerant to ACE inhibitors or angiotensin II (AII)
receptor antagonists.
Amiodarone: prevention of arrhythmias in patients with symptomatic ventricular arrhythmias.
*Prefer long-acting drugs such as lisinopril or ramipril unless patient is haemodynamically unstable, in which case short-
acting captopril once or twice daily is useful for initiating therapy
Table 5.1 Arrhythmias
Arrhythmia Basic pathology Medical management Intervention or surgical management
Non-MI related
AF or atrial flutter Increasing prevalence with age Control rate with digoxin/β blocker/amiodarone Persistent flutter/fibrillation needs
and restore to sinus rhythm by chemical anticoagulation with warfarin and
Look for possible underlying causes:
(flecainide/amiodarone)/electrical cardioversion consideration for DC cardioversion,
Cardiac: mitral valve disease, IHD, depending on underlying pathology.
Heparin and/or warfarin needs to be considered
pericarditis, cardiomyopathy, endo- Electrophysiological ablation can be
/myocarditis, post-cardiac surgery If patient hypotensive consider immediate DC very successful and should be
cardioversion considered
Atrial myxoma
Acute AF or flutter often reverts spontaneously Occasionally AV node ablation and a
Lung pathology: pneumonia, pulmonary
within 24 h permanent pacemaker are needed to
embolic malignancy, trauma/surgery
control heart rate for those not
Correct underlying cause if possible
Metabolic: thyrotoxicosis, alcohol excess, responsive to other medical therapy
electrolyte imbalance/acidosis
SVT Accessory pathway between atria and DC cardioversion if hypotensive Consider atrial overdrive pacing
ventricles causing a re-entrant circuit,
Vagal manoeuvres, e.g. carotid massage/Valsalva Electrophysiology studies and
e.g. Wolff–Parkinson–White syndrome,
manoeuvre ablation if medical treatment is not
AV node re-entrant tachycardia
adequate
Intravenous adenosine (3–12 mg)
Ectopic atrial focus or AF/atrial flutter
Consider intravenous verapamil or β blocker
VT Associated with IHD, hypertensive heart Synchronized DC cardioversion if hypotensive. If Consider electrophysiological
disease, cardiomyopathy stable give intravenous lidocaine studies/ablation or implantable
defibrillator
Can be precipitated by bradycardia, Correct metabolic abnormalities
hypokalaemia, hypomagnesaemia, MI or
Amiodarone may be necessary to stabilize patient
long Q–T interval
115
Arrhythmia Basic pathology Medical management Intervention or surgical management
Ventricular Ectopic focus within ventricle Treatment offers no benefit to survival
116
premature beats
Give anti-arrhythmic if symptomatic (β blocker)
Torsades de pointes Associated with inherited or acquired Correct electrolyte imbalance Consider temporary pacing
prolongation of Q–T interval, e.g. drugs,
Stop drugs prolonging Q–T interval
hypokalaemia, hypomagnesaemia,
hypocalcaemia, IHD Intravenous magnesium
Consider β blocker in hereditary long Q–T interval
VF See Case 5.4 See Case 5.4 See Case 5.4

Post-MI arrhythmias
AF/flutter AF is often transient post-MI Rate control
Usually reverts spontaneously
Treat as above if persistent
VF Acute MI is a common cause of VF As non-MI treatment Recurrent or late VF (> 48 h)

indicates risk of subsequent sudden
Note that anti-arrhythmic drug treatment is not
death and these patients should be
necessary after VF within the first 24 h of acute MI
considered for coronary angiography
and electrophysiological studies
VT Associated with IHD, especially acutely Treatment as above Recurrent or late VT (> 48 h)
post-MI indicates risk of subsequent sudden
Note that anti-arrhythmic drug treatment is not
death and these patients should be
necessary after VT within the first 24 h of acute
considered for coronary angiography
MI
and electrophysiological studies
Ventricular Common acutely post MI/post Often no treatment is required

premature beats thrombolysis
Sinus bradycardia Commonly complicates RV If heart rate is < 60 beats/min with hypotension Temporary or permanent pacing may
infarction/inferior infarction or cardiac failure, give atropine 0.6 mg i.v. be needed
AV block Commonly complicates RV First-degree heart block requires no treatment. Temporary or permanent pacing may
infarction/inferior infarction Second- and third-degree heart block with inferior be needed
infarction require treatment only if associated
Second- or third-degree heart block
with hypotension, syncope, cardiac failure or
associated with anterior infarction
‘escape’ ventricular arrhythmias. Atropine 0.6 mg
should be always considered for
i.v. bolus up to 3 mg i.v. can be given
temporary pacing because it may
progress to ventricular standstill.
AF, atrial fibrillation; AV, atrioventricular; DC, direct current; IHD, ischaemic heart disease; MI, myocardial infarction; SVT, supraventricular tachycardia; VF, ventricular fibrillation; VT,
ventricular tachycardia.
117
118 Cardiology
Cardiac arrest
Precordial thump if appropriate
BLS algorithm if appropriate
Universal ALS
Attach defib-monitor
algorithm
Assess
rhythm
VF/VT +/– check pulse Non-VF/ VT
During CPR
Defibrillate ×3
Correct reversible causes
as necessary If not already:
• check electrodes, paddle position CPR 3 mins*
and contact *1 min if immediately
CPR 1 min • attempt / verify airway & O2 after defibrillation
i.v. access
• give epinephrine every 3 min
Consider:
amiodarone; atropine/pacing buffers
Potential reversible causes:

• Hypoxia
• Hypovolaemia
• Hypo / hyperkalemia & metabolic disorders
• Hypothermia
• Tension pneumothorax
• Tamponade
• Toxic/therapeutic disorders
• Trombo-embolic & mechanical obstruction
Figure 5.1 Universal ALS Algorithm

Key concepts 119
Right coronary artery Left coronary artery
Left anterior
descending
Circumflex
artery
Anterior MI
*Posterior MI
*Inferior MI
aVR
I V1
V4
aVL V2 V5
II
aVF V6
III V3
*There is an overlap between inferior and posterior depending on the patient’s anatomy, i.e. whether the RCA
is the dominant artery or the circumflex.
Figure 5.2 Chest pain

Table 5.2 Valvular heart disease
Cause Symptoms Signs Management
120
Aortic stenosis Degenerative (± calcification) Symptoms usually only occur Slow rising pulse and narrow Valve replacement if symptomatic
when the aortic orifice is reduced pulse pressure. Thrusting non- and high valve gradient on
Calcification of congenital
to a third of its normal size: displaced or displaced apex. An echocardiogram
bicuspid valve
angina, dyspnoea and exercise- ejection click may precede the
Valvuloplasty in young patients
Occasionally rheumatic fever induced syncope harsh ejection systolic murmur
which is loudest over the right
upper sternal edge and radiates to
the carotids
Aortic Damage of aortic valve cusps: Usually asymptomatic unless Collapsing pulse and wide pulse Diuretics and vasodilators for mild
regurgitation severe. Exertional dyspnoea and pressures. Nail-bed capillary symptoms
bicuspid aortic valve
fatigue pulsations (Quincke’s sign), head
(congenital) Valve replacement once patient is
nodding (deMusset’s sign), and
symptomatic or if the left ventricle
infective endocarditis ‘pistol shot’ sounding femoral
is dilating
arteries are sometimes seen. Apex
rheumatic fever
is laterally displaced and
Dilatation of aortic root/valve thrusting. There is an early
ring: diastolic murmur at the lower left
sternal edge that is heard best
arthritides, e.g. Reiter’s
with the patient sitting forward in
syndrome, ankylosing
full expiration
spondylitis
severe hypertension
aortic dissection
rare causes, e.g. Marfan’s

syndrome, syphilis
Mitral stenosis Rheumatic fever Exertional dyspnoea, cough ± AF, malar flush, palpable first heart Valvuloplasty if valve is not
haemoptysis, palpitations sound (‘tapping’ apex). Loud first calcified and no significant MR
heart sound, opening snap in early
Valve replacement
diastole followed by rumbing mid-
diastolic murmur at apex with
presystolic accentuation.
Pulmonary hypertension, RVH and
eventually right heart failure
MR Mitral valve prolapse (MVP) Exertional dyspnoea and lethargy. Laterally displaced apex. Soft first Diuretics and ACE inhibitors
Pulmonary oedema if acute heart sound. Pansystolic murmur
Rheumatic fever Valve repair or replacement if
regurgitation loudest at apex and radiating to
symptomatic or progressive LV
Papillary muscle axilla and throughout precordium.
dilatation
dysfunction/rupture post-MI Third heart sound often present
LV dilatation
Endocarditis
Rare causes: SLE, Marfan’s

syndrome
MVP Unknown cause (more Usually asymptomatic. Can Midsystolic click ± murmur. MR β Blockers if symptomatic
common in women) present with atypical chest pain or may occur
palpitations
Associated with Marfan’s
syndrome/IHD
TS Rheumatic fever Usually associated with mitral and Valvuloplasty or valve replacement
aortic valve disease which
Carcinoid
dominate the symptoms and signs
121
Cause Symptoms Signs Management
TR Raised pulmonary pressure Symptoms and signs of Raised JVP with giant ‘v’ waves, If functional, signs usually improve
122
(look for cause e.g. PE, lung underlying lung pathology may be pulsatile liver and pansystolic with diuretic therapy
disease, left heart causes present, and of right heart failure murmur at the lower left sternal
Annuloplasty or replacement very
[MV disease, LV edge, accentuated with
rarely required
dysfunction]) inspiration. Peripheral oedema
and ascitis may be present
Can be physiological
Rare causes: rheumatic heart

disease, infective
endocarditis, carcinoid
PS Congenital (usually with Fatigue, syncope, RV failure Systolic murmur at the left sternal Valvuloplasty
other defects, e.g. Fallot’s edge. Signs of right heart failure
Valve replacement
tetralogy)
PR Pulmonary hypertension Usually asymptomatic Early diastolic murmur at the Treatment rarely needed
upper left sternal edge
Endocarditis (intravenous
drug abusers)
VSD Congenital May be asymptomatic Pansystolic murmur loudest at the Repair of VSD
third or fourth intercostal space
Post-MI (ventricular septal Eisenmenger’s syndrome occurs
rupture) later in life when pulmonary Pulmonary hypertension signs
vascular disease develops may be present
ASD Congenital Arrhythmias and heart failure Wide fixed splitting of S2. Surgical or percutaneous closure if
Pulmonary ejection systolic symptomatic or developing
murmur as a result of increased Eisenmenger’s syndrome
flow. Pulmonary hypertension
with TR or PR may occur
ACE, angiotensin-converting enzyme; AR, aortic regurgitation; ASD, atrial septal defect; AF, atrial fibrillation; IHD, ischaemic heart disease; JVP, jugular venous pressure; LV, left
ventricular; MI, myocardial infarction; MR, mitral regurgitation; MV, mitral valve; PE, pulmonary embolus; PR, pulmonary regurgitation; PS, pulmonary stenosis; RV, right ventricular;
RVH, right ventricular hypertrophy; SLE, systemic lupus erythematosus; TR, tricuspid regurgitation; VSD, ventricular septal defect.
Answers 123
Answers
CASE 5.1 – A 34-year-woman with palpitations.
A
A1
Elicit from the history the onset of symptoms and any associated features (chest pain, dyspnoea, nausea, tremor, etc.). The
patient’s symptoms may be related to the arrhythmia or an ischaemic event might have caused it. The patient may be able
to identify whether the rhythm is regular or irregular, or tap out the arrhythmia. Determine if the palpitations have occurred
in the past. Ask specifically for precipitating or relieving factors, and for any medical conditions that the patient may have
that predispose to arrhythmias, e.g. thyrotoxicosis, valvular heart disease. A drug history is very important because some
drugs may precipitate arrhythmias or influence the arrhythmia’s management (e.g. verapamil must not be given in patients
already on β blockers because it may result in circulatory collapse).
A2
Atrial fibrillation (AF) secondary to thyrotoxicosis as a result of the history of diarrhoea and insomnia that are features in
this condition. Other causes of arrhythmia to consider are described in the Key concepts.
A3
A full physical examination is necessary. Determine the rate, character and volume of the pulse. Note if the patient is
haemodynamically stable: record the blood pressure (BP) and examine for signs of heart failure. Auscultate for heart
murmurs. Examine for thyroid status if appropriate.
A4
If the patient has a tachycardia and is haemodynamically unstable (systolic BP < 80 mmHg, reduced level of consciousness,
severe pulmonary oedema) consider immediate DC (direct current) cardioversion. If the patient has a bradycardia and is
haemodynamically compromised, give atropine 0.6–1.2 mg i.v. If there is persistent bradycardia, consider external pacing
while organizing transvenous pacing wire insertion. See Key concepts.
124 Cardiology
A5
Record a 12-lead ECG to determine the nature of the arrhythmia (regular versus irregular, narrow versus broad QRS
complex). Take blood for routine haematology, biochemistry, calcium, magnesium, cardiac enzymes, thyroid function tests
and glucose. A chest radiograph is useful to estimate heart size and look for signs of pulmonary oedema.
A6
This depends on the arrhythmia and its underlying cause (see Key concepts).
CASE 5.2 – A 53-year-old man with sudden onset of chest pain.
A
A1
There is a wide range of differential diagnoses for chest pain and it is thus very important to establish the exact nature of
the pain. A constricting central chest pain that occurs on exertion and is relieved by rest or GTN suggests angina. A similar
crushing central chest pain when more prolonged and of greater severity indicates myocardial infarction (MI). Unlike angina
this pain is not relieved by rest or GTN and is typically associated with extreme distress, sweating, nausea ± vomiting and
dyspnoea. Cardiac pain usually radiates to one or both arms and up the neck to the jaw. Risk factors for IHD to seek are:
diabetes mellitus, hypertension, hyperlipidaemia, smoking, and any family history of IHD. Male sex, increasing age and
obesity are also risk factors. Other causes of chest pain to consider include: pericarditis, dissecting aortic aneurysm,
pulmonary embolus (PE), pleurisy, gastro-oesophageal reflux, perforated peptic ulcer, pancreatitis and cholecystitis.
A2
The most likely diagnosis is MI. This is usually caused by rupture of an atherosclerotic plaque with formation of thrombus
and complete occlusion of a coronary artery.
A3
A full physical examination is needed. The patient is usually very distressed and appears pale, grey and sweating. The pulse
must be noted because arrhythmias are common, particularly if the MI is of the right coronary artery, which supplies the
sinoatrial node. Hypotension may also occur and the BP is often measured in both arms to look for any significant
Answers 125
difference (> 15 mmHg) that may indicate aortic dissection. The jugular venous pressure (JVP), if raised, indicates right
heart failure and right ventricular (RV) infarction must be considered. Listen for any murmurs and then examine for
pulmonary oedema. Cardiogenic shock can be recognized from the following: systolic BP < 90 mmHg, heart rate >100
beats/min or < 40 beats/min, the presence of pulmonary oedema (oxygen saturation < 90 per cent), cold peripheries,
agitation or confusion and oliguria.
A4
Immediate treatment is aimed at relief of pain, limitation of infarct size and management of complications if they arise.
Oxygen is administered via a facemask (28 per cent if history of chronic bronchitis/emphysema) and the patient is attached
to an ECG monitor. Intravenous access is obtained and 5 mg diamorphine given along with 10 mg metoclopramide as an
antiemetic. Further 2.5 mg boluses of diamorphine should be given until the patient is pain free. Soluble aspirin 300 mg
and sublingual GTN (provided that the patient is not hypotensive) must also be given if not already administered by the
ambulance paramedics. A 12-lead ECG is done as a priority to decide whether thrombolysis is appropriate. Thrombolysis
given within 4 h of pain onset, using streptokinase or recombinant tissue plasminogen activator (rtPA) with intravenous
heparin, will achieve reperfusion in 50–70 per cent of patients (compared with 20 per cent of controls). Primary coronary
angioplasty should be considered if available. See Key concepts.
A5
The diagnosis is usually made on the basis of a history and 12-lead ECG, and confirmed later with a rise in cardiac
enzymes. ST-segment elevation on the ECG occurs within minutes and is followed by T-wave inversion that persists after the
ST segment returns to baseline. The indication of transmural infarction is the development of Q waves, usually hours or
days later. The infarct site may be determined by the location of ECG changes. Other ischaemic changes on the ECG that
may occur are new left bundle-branch block (LBBB), right bundle-branch block (RBBB), tachy- or bradyarrhythmias, left or
right axis deviation or atrioventricular (AV) block. Creatine phosphokinase (CPK) is the cardiac enzyme routinely measured
(rises at 4–8 h, peaks at 24 h and returns to normal in 3–4 days) but the CK-MB isoenzyme and troponin myofibrillar
protein (rises within 4 h and remains elevated for up to 2 weeks) are more specific for myocardial disease and
diagnostically more reliable. A chest radiograph to determine cardiac size and look for pulmonary oedema must be
performed. Blood must be taken for routine haematology and biochemistry investigations, and for random glucose and
cholesterol measurement.
A6
Patients should be admitted to the coronary care unit (CCU) if possible and have bedrest for 24–36 h. Subcutaneous
heparin is used as prophylaxis against deep venous thrombosis (DVT). Uncomplicated MI patients can be discharged home
after 5 days. Complications that may occur include: cardiogenic shock, reinfarction, dysrhythmias, pericarditis, acute mitral
regurgitation (AMR), ventricular septal defect (VSD) and myocardial rupture. In cases where pain persists or there is no
resolution of ST elevation, patients are considered for repeat thrombolysis or referred for urgent angiography with the aim
of revascularization, usually by coronary angioplasty. Secondary prevention post-MI is important and each patient will be
126 Cardiology
prescribed aspirin, a β-adrenoceptor blocker, ACE inhibitor and a lipid-lowering statin, unless specific contraindications are
present. On discharge, patients should be advised to inform the DVLA (Driver and Vehicle Licensing Authority) of their
admission; they can usually resume driving in 6 weeks and return to work in 3 months. Every patient should be entered
into a cardiac rehabilitation programme and have active follow-up.
CASE 5.3 – An 80-year-old patient collapses, requiring CPR.
A
A1
Obtain as much history as possible from the daughter and paramedics. Events immediately preceding the arrest are
particularly important because they may indicate the cause. Enquire specifically about any illness that the patient may have
had and obtain a past medical history: IHD, diabetes mellitus (consider hypoglycaemia), depression (drug overdoses), etc.
Establish the medication that she is on and enquire about illicit drug use if appropriate (especially in a young patient where
examination may yield evidence of intravenous drug abuse). It is also important to identify the length of time before
resuscitation and the duration of resuscitation before admission. Without CPR, permanent cerebral dysfunction occurs after
3–4 min of cardiopulmonary arrest. The longer the period of arrest, the less likely it is that resuscitation will be successful
and the patient restored to a healthy life.
A2
The most common cause of a cardiac arrest is ventricular fibrillation (VF). Other causes include other dysrhythmias
(pulseless ventricular tachycardia, brady-dysrhythmia), sudden pump failure (MI), circulatory obstruction (PE) and
cardiovascular rupture (myocardial rupture/dissecting aortic aneurysm).
A3
The initial assessment of the airway/breathing/circulation (ABC) would have already been performed by the paramedics.
Examine the patient briefly to check that CPR is effective: palpate for a pulse and check that both lungs are ventilated.
Look for any signs of bleeding such as haematemesis or melaena that may suggest hypovolaemia as the cause of the
arrest. If the abdomen is distended, an intra-abdominal catastrophe such as a ruptured abdominal aortic aneurysm may be
suspected.
A4
Effective basic life support (BLS) and early defibrillation are the most vital elements of successful resuscitation. The patient
is already being resuscitated by the paramedics and intravenous access has usually been established. Attach the patient to
Answers 127
a defibrillator via ECG leads to determine whether the cardiac rhythm is ‘shockable’ (VF/pulseless ventricular tachycardia
[VT]) or not (asystole/electromechanical dissociation). If the patient is in a ‘shockable’ rhythm, DC cardioversion should be
given without delay. Continue advanced CPR according to the algorithm determined by the patient’s cardiac rhythm each
time it is assessed (see Key concepts). The patient should be intubated if this has not already been done. Adrenaline or
epinephrine (1 mg i.v.) should be given every 3 min and, if the patient is in asystole, 3 mg atropine should be given once
only. In refractory VF/VT (after four cycles of advanced life support [ALS]), amiodarone is recommended. An arterial blood
gas is taken during ALS and if hyperkalaemia is present, calcium chloride is administered. Bicarbonate can be given in
severe acidosis (pH<7.0) and in hyperkalaemia. Treatable causes must be considered (see algorithm) and where possible
an attempt at correcting them made.
A5
In the event of successful resuscitation a 12-lead ECG must be done to look for evidence of MI that may have precipitated
the arrest. A chest radiograph may show pulmonary oedema or identify rib fractures secondary to vigorous CPR, and is
useful to check the position of the endotracheal (ET) tube. Routine blood biochemistry, haematology, cardiac enzymes,
glucose, and group and save are taken, and blood cross-matched if a bleed is suspected. An arterial blood gas (ABG) will
indicate whether ventilation is adequate.
A6
Most patients need admission to intensive care post-arrest and may require ventilation and support with inotropes such as
adrenaline. They may require a central line. A member of the medical team must speak with the family and inform them of
the future management and likely prognosis.
CASE 5.4 – A 65-year-old with tearing chest pain.
A
A1
Establish the nature of the pain. Aortic dissection pain can mimic MI, and caution must be taken to distinguish the two
because treatment is different. Abrupt onset of tearing chest pain that radiates to the back and abdomen indicates
dissection. Patients may present with symptoms and signs of occlusion of one or more of the branches of the aorta as the
dissection progresses: stroke, limb ischaemia, paraplegia, MI. Risk factors to enquire about include: hypertension,
arteriosclerosis (IHD/peripheral vascular disease [PVD]), pregnancy or a history of trauma, and rarely Marfan’s syndrome.
128 Cardiology
A2
The most likely diagnosis is aortic dissection. This may be proximal (type I starts in ascending aorta but progress down the
aorta, type II is localized to ascending aorta) or distal (type III starts in the descending aorta after the arch), involving the
descending aorta only.
A3
A full examination is necessary. A BP difference between the right and the left arm (> 15 mmHg) occurs in 10 per cent of
patients with a dissection. A difference in pulse between right and left arm or radial to femoral pulse. An elevated JVP and
pulsus paradox indicate cardiac tamponade caused by rupture of the aortic wall into the pericardium. Aortic regurgitation
may be heard when the aortic root is involved. Examine for any neurological deficit.
A4
Resuscitation is the initial management. Oxygen must be given via a facemask. Intravenous access is established and pain
relief with diamorphine given. Systolic BP must be reduced to 100–120 mmHg using drugs that decrease the inotropic
force of the heart, e.g. labetolol infusion.
A5
The diagnosis of aortic dissection can be made in several ways. The diagnosis is often suspected from the chest radiograph,
which may demonstrate a widened mediastinum. However, this is an unreliable sign and chest computed tomography (CT)
with contrast or magnetic resonance imaging (MRI) is usually preferred to make the diagnosis non-invasively. An
echocardiogram is also useful to look at the aortic root in detail in type I or II dissection, but a transoesophageal
echocardiogram is preferred if possible to obtain detailed views of the descending thoracic aorta. Cardiac catheterization
will aid planning of surgical repair.
A6
Over 50 per cent of patients die in the first 24 h of presentation. Urgent surgical repair is needed in type I or II dissection,
and frequently in type III, if the patient is to have a chance of survival.
Answers 129
CASE 5.5 – A 25-year-old man with a heart murmur.
A
A1
Elicit from the history whether the patient has any symptoms suggestive of valvular stenosis or regurgitation: dyspnoea,
oedema, dizziness, syncope, palpitations or chest pain. Haemoptysis or recurrent bronchitis may indicate pulmonary
hypertension. A past medical history may suggest a cause, e.g. rheumatic heart disease, MI causing papillary muscle
rupture. Consider underlying conditions and family history that may predispose to valvular abnormalities, e.g. dilated or
hypertrophic cardiomyopathy, Marfan’s syndrome or ankylosing spondylitis. Ask about any symptoms that may suggest
endocarditis (rash, fevers) or predisposing factors such as intravenous drug abuse.
A2
A heart murmur is heard when there is turbulent blood flow, the cause usually being an abnormal heart valve that may be
incompetent (regurgitant), stenotic or both. An ‘innocent murmur’ produced by a normal heart valve tends to occur in the
setting of a hyperdynamic circulation, e.g. anaemia, thyrotoxicosis, pregnancy. See Key concepts for causes of each murmur.
A3
A full physical examination is necessary. Determine the characteristics of the pulse and BP. Look for signs of right heart
failure: raised JVP, ankle oedema, enlarged liver and for pulmonary oedema indicating LV failure. Determine whether the
murmur is systolic or diastolic. The character of the murmur (e.g. pansystolic in mitral regurgitation) and the location and
radiation of the murmur will give further clues to the diagnosis (see Key concepts). Bear in mind that a soft, midsystolic
murmur that varies with posture and is not associated with signs of heart disease is usually benign.
A4
Medical therapy is mainly aimed at treatment of complications (AF, heart failure). Surgical treatment may be valve repair,
valve replacement or valvotomy (see Key concepts). Surgery must be performed before irreversible LV dysfunction and
pulmonary oedema become established.
130 Cardiology
A5
Valve dysfunction is confirmed with echocardiography ± cardiac catheterization (to define the haemodynamics of the
lesion). An ECG may show LV hypertrophy and confirm AF or, if in sinus rhythm, show the bifid P wave (‘P mitrale’) of left
atrial hypertrophy in mitral stenosis or the tall P wave (‘P pulmonale’) of pulmonary hypertension. A chest radiograph may
indicate cardiomegaly.
A6
Prosthetic valves are either mechanical (e.g. Starr–Edwards ball-and-cage valve, Björk–Shiley tilting disc valve) or
bioprosthetic valves (porcine xenograft). Bioprosthetic pig valves typically degenerate after about 10 years and are hence
preferably used in elderly people. Mechanical valves last longer but need lifelong anticoagulation. All prosthetic valves and
native abnormal valves are susceptible to infection. Patients should always be advised that antibiotic prophylaxis is
necessary if they undergo any procedure that may induce bacteraemia, e.g. surgical or dental procedures.
OSCE Counselling Cases – Answers 131

OSCE COUNSELLING CASE 5.1 – ‘Can I stop my warfarin (anticoagulation in a
patient with prosthetic heart valve)?’
The answer is definitely NO! Anticoagulation must never be stopped in a patient with a metal heart valve.
If she stops anticoagulation, there is a significant risk of thrombosis, especially in the hypercoagulable state of pregnancy. A
clot may obstruct the valve, causing sudden stenosis, or embolize and cause a stroke.
However, her worries are genuine. Warfarin does indeed have teratogenic effects and can also cause intracerebral
haemorrhage in the fetus. Women that continue warfarin throughout pregnancy have approximately a 7 per cent chance of
having a baby with a congenital abnormality and a further 16 per cent risk of stillbirth or spontaneous abortion. There are
also increased complications after delivery.
The answer is to advise the patient to change to heparin for the first 3 months of the pregnancy, restart warfarin at 3
months and change again to heparin 2–4 weeks before the expected delivery date. Heparin is not teratogenic but it must
be noted that it is also associated with a higher risk of abortion and a higher incidence of bleeding.
Another point of note is that warfarin is excreted in breast milk (in small amounts) and it is advisable that mothers on
warfarin should not breast-feed if possible.
OSCE COUNSELLING CASE 5.2 – The use of anti-anginal medication.
GTN
Nitrates are potent vasodilators, but the main benefit in angina is by causing a reduction in venous return, which reduces
LV work. Sublingual GTN is used to treat symptoms in angina on an as-required basis. It comes in spray or tablet form, with
the advantage of the spray having longer storage life once opened. The onset of action is 1–2 min and effects last for up to
20 min. Sublingual GTN can be taken repeatedly but patients should be advised to seek medical attention if they do not
get any relief after repeated use.
Headaches are common, especially in the first few days after starting treatment. Patients can be advised that if the
headache is severe they can spit the tablet out or swallow it in order to deactivate it. Flushing and postural hypotension
causing syncopal attacks are also reported and may limit therapy.
b BLOCKERS
β Blockers decrease myocardial oxygen demand by causing a fall in heart rate, BP and decreasing myocardial contractility.
However, they are contraindicated in asthma and chronic obstructive pulmonary disease (COPD), and relatively
contraindicated in diabetes mellitus, PVD and severe LV dysfunction.
Lethargy is a common side effect and interference with exercise capacity may cause patients to discontinue their
medication. Coldness of extremities and sleep disturbances may also lead to non-compliance. Bradycardia and other
conduction disorders may also occur.
132 Cardiology
OSCE COUNSELLING CASE 5.3 – ‘I have heart failure. Do I need to take my

medications for life?’
Unfortunately a diagnosis of heart failure (in this case moderate to severe on echocardiogram) is associated with a worse
prognosis than most cancers (50 per cent 5-year mortality rate if untreated). With correct therapeutic management his
symptoms will improve and his annual risk of death will be cut by half.
It is very important to use medications that have been used in large randomized trials that have been shown to be effective
(see Key concepts).
Ask the patient whether he is having any particular problem with the drugs prescribed, particularly symptoms of
hypotension.
Advise the patient that, if possible, the dose of bisoprolol may be increased to try to get to the target dose of 10 mg once
daily.
Advise the patient that he will require regular blood checks (initially 1–2 weekly and then 3 monthly watching for
hyperkalaemia and rising creatinine) because of the potential interaction between ACE inhibitors and spironolactone.
In addition the patient should be advised to monitor his weight regularly and seek advice should it rise because it may be a
sign of fluid overload.
6Care of elderly people
Peter Wallis
134 Care of elderly people
FALLS

Q1: What is the differential diagnosis?
Q2: What features in the history support the diagnosis?
Q3: What additional features in the history would you seek to support the potential diagnoses?
Q4: What other features would you look for on clinical examination?
Q5: What investigations would you perform?
Q6: What treatment options are available?
Clinical cases
CASE 6.1 – A 71-year-old man has been brought to the accident and emergency
department (A&E) after a fall whilst shopping.
He lost consciousness momentarily and has little recollection of the event. He admits to previous episodes of dizziness,
sometimes on exertion and often associated with shortness of breath.
His past history includes a hiatus hernia, diverticular disease, and osteoarthritis of his neck and knees. He is taking regular
omeprazole, a dietary fibre supplement and a compound analgesic containing paracetamol and codeine (codamol).
Examination discloses a regular pulse and blood pressure (BP) of 114/76 mmHg. There is an ejection systolic cardiac
murmur radiating to the neck. The lung fields are clear. Neurological examination is normal.
CASE 6.2 – An 82-year-old woman presents with recurrent falls.

She is housebound. Her most recent fall occurred while getting up to go to the toilet at night. She has arthritis, heart failure
and poor vision as a result of macular degeneration, and has had a previous hip replacement. She receives treatment with
furosemide, ramipril, co-codamol (paracetamol/codeine compound analgesic), dothiepin and temazepam.
She is very frail. The main findings on examination are: abbreviated mental test 6/10, vision – large print only, kyphotic
spine, brisk reflexes bilaterally; peripheral oedema, clear lung fields and normal jugular venous pressure (JVP); heart rate
(HR) 112/min atrial fibrillation (AF); BP sitting 114/62 mmHg, mitral regurgitation.
CASE 6.3 – A 78-year-old man who lives alone is brought to A&E after being
found on the floor at home by his neighbour.
He is confused and disorientated. His head is bruised and he appears unkempt. He is immobile and there is cog-wheel
rigidity in all his limbs. There are no focal neurological signs. Reflexes are hard to elicit as a result of the muscle stiffness.
Plantar responses are down-going. There are signs of a lower respiratory tract infection. Temperature is 38.2°C, BP 102/60
mmHg, HR 94/min.
Falls 135
Investigation discloses:
Normal plasma glucose and electrolytes
Urea 24 mmol/L
Creatinine 142 µmol/L
Haemoglobin (Hb) 15.5 g/dL
White cell count (WCC) 14.3 × 109/L
Platelets 342 × 109/L
Chest radiograph: consolidation right lower lobe
ECG: sinus tachycardia.

OSCE COUNSELLING CASE 6.1 – What advice would you give?
An elderly housebound woman has fallen at home on several occasions and has recently attended A&E with a Colles’
(wrist) fracture. Her daughter is concerned about the presence of osteoporosis and seeks your advice at the surgery about
the need for calcium tablets in order to prevent further fractures.
OSCE COUNSELLING CASE 6.2 – A house-bound 94-year-old woman with epilepsy

(controlled with phenytoin) presents with falls,
weakness and generalized aches and pains.
Biochemical tests reveal:
Calcium (corrected) 1.85 mmol/L (normal range 2.05–2.60 mmol/L)
Phosphate 0.68 mmol/L (normal range 0.8–1.45 mmol/L)
Albumin 32 g/L (normal range 35–48 g/L)
Alkaline phosphatase (ALP) 458 U/L (normal range 30–200 U/L).
Q2: What factors might have precipitated this condition?
Q3: What signs would you look for on examination?
Q4: How would you treat the condition?

Key concepts
Older people are at much greater risk of falling and most falls occur at home. Nevertheless the risk of falling is much higher
in those older people who reside in an institutional environment such as a residential or nursing home or hospital, as a
result of the increased frailty of this group. One-third of people aged over 65 will fall in a year, often repeatedly. Falls
resulting in injury are a leading cause of death in older people, accounting for two-thirds of injury-related deaths in those
aged 85 and over. Of course, most falls do not result in death, but can give rise to substantial morbidity. The fear of falling
often leads to loss of confidence, increased dependence on others and restriction of activity.
Most patients fall because of age-related and/or disease-associated damage to one or more systems essential for the
maintenance of balance and posture. Vision, vestibular, sensory, locomotor, cardiovascular and central processing
mechanisms are all important in this regard. A careful history detailing the circumstances surrounding the fall is essential.
Often there is little recollection of the prodromal events, so corroborative information from a witness is invaluable. Accurate
diagnosis, treatment of predisposing illness and amelioration of risk factors such as impaired vision, polypharmacy,
inadequate footwear and environmental hazards are all important. Multidisciplinary falls clinics (with physiotherapy and
occupational therapy support) and exercise programmes can reduce the risk of falling.
Many falls result in bone fractures. Effective treatments for osteoporosis in older patients include bisphosphonates as well
as calcium and vitamin D supplements. The latter are preferred for older people who are housebound or cared for in a
residential or nursing home setting. Hip protectors can reduce the risk of femoral neck fractures in selected frail older
people when worn.
Falls 137
Answers
CASE 6.1 – A 71-year-old man has been brought to A&E after a fall whilst
shopping.
A1
Aortic stenosis
Cardiac arrhythmia
Silent myocardial infarction (MI)
Postural hypotension
Vasovagal episode
Vertebrobasilar transient ischaemic attack (TIA).
A2
The syncopal event occurred on exertion and this is consistent with significant aortic stenosis. In this situation, syncope can
be precipitated by impaired cardiac output or a transient arrhythmia such as ventricular tachycardia. The history of previous
exertional dizziness and breathlessness lends support to this diagnosis.
Silent MI and/or cardiac arrhythmia must be considered too. Myocardial infarction can present without chest pain,
particularly in older patients.
Postural hypotension – postural dizziness when standing (e.g. arising from bed at night) – might be volunteered. Enquire
about medications with hypotensive properties (e.g. diuretics, antihypertensives, antidepressants). Co-proxamol is not
usually a cause of postural hypotension, but the opiate component (dextropropoxyphene) can impair balance.
Vasovagal episodes are a common cause of syncopal events, particularly in younger patients. In this case, the presence of
other cardiac symptoms and signs makes the diagnosis unlikely.
Finally, the patient does have an arthritic neck. When severe, this can compromise the vertebrobasilar circulation, especially
if there is significant atheroma affecting the vertebrobasilar system and circle of Willis. The apparent absence of sudden
neck movement before syncope and the lack of other features such as dizziness, vertigo or sudden loss of tone in the legs
(‘drop attack’) makes this diagnosis less likely.
A Q3: What additional features in the history would you seek to support the
potential diagnoses?
A3
The presence of exertional chest pain (angina) and dyspnoea supports the diagnosis of aortic stenosis (SAD = syncope,
angina, dyspnoea).
A4
Aortic stenosis – the following might be present:
Ejection systolic murmur radiating to the neck
Slow rising pulse
Low pulse pressure
Ejection click sometimes heard
Early diastolic murmur if there is also aortic regurgitation
Quiet second heart sound
Silent MI
Signs of heart failure
Cool, clammy peripheries resulting from low cardiac output
Fall in standing BP < 20 mmHg associated with symptoms of dizziness/faintness
Vertebroasilar ischaemia.
Symptoms are sometimes precipitated by head movement.
A5
ECG, chest radiograph, cardiac enzymes and/or troponin testing, echocardiography and ECG (Holter) monitoring. Full blood
count, uka and electrolytes and blood glucose also necessary.
A6
A precise diagnosis is essential first. If aortic stenosis is severe, referral to a cardiologist for consideration of valve
replacement. The patient should be advised to avoid sudden strenuous exertion in the meantime.
Admission necessary if MI or arrhythmia suspected.
Postural hypotension: discontinuation or reduced dose of offending medication, avoidance of precipitating events,
compression hosiery.
Aspirin for TIA.

Falls 139
CASE 6.2 – An 82-year-old woman presents with recurrent falls.
A1
Multiple causes including:
Poor vision
Polypharmacy
Neurological dysfunction: previous strokes, cervical myelopathy, vitamin B12 deficiency all possible
Arthritis/Osteomalacia
Arrhythmia – atrial fibrillation (AF).
A2
Poor vision: the fall occurred at night when environmental hazards are more difficult to see and avoid.
Postural hypotension: the fall occurred while getting out of bed to go to the toilet. She is on a lot of medications that
can impair postural BP control, i.e. a diuretic, an angiotensin-converting enzyme (ACE) inhibitor and dothiepin (a
tricyclic antidepressant with anticholinergic properties).
Polypharmacy: postural hypotension as above:
– impaired balance and cognition caused by temazepam, opiate analgesic and tricyclic antidepressant
– muscle weakness: diuretic-induced hypokalaemia.
Neurological dysfunction: brisk reflexes are suggestive of upper motor neuron (UMN) dysfunction. Common causes at
this age include stroke disease, cervical myelopathy and occasionally vitamin B12 deficiency. As a result of the history of
falls, a chronic subdural haematoma should be considered as well.
AF: poorly controlled (rapid) ventricular rate on exertion causing syncope. AF might also be a manifestation of sick
sinus syndrome, predisposing to supraventricular tachycardia or bradycardia.
A3
Poor vision: access to spectacles, ability to read or identify objects, adequacy of lighting in the home.
Postural hypotension: dizziness or falls when upright with associated symptoms of faintness or even syncope with
rapid recovery when recumbent.
Polypharmacy: concordance with medication regimen and any potential to exceed the intended dosing schedule.
Neurological dysfunction.
History suggestive of previous stroke or TIA.
Neck arthritis with giddiness on head movement (especially looking upwards), pain radiating to shoulders/upper limbs
(cervical spondylitic radiculopathy) would both suggest cervical myelopathy as a potential cause of falling.
Enquire about diet, previous gastric surgery, bowel (terminal ileal) resection, anaemia and symptoms of sensory
neuropathy in suspected vitamin B12 deficiency.
Fluctuating alertness (and confusion) or consciousness with history of falls and head injuries (even trivial) should
highlight the possibility of subdural intracranial bleeding.
Bone pains and muscle weakness in a housebound woman with poor diet point to osteomalacia.
Cardiac arrhythmia: recurrent episodes of dizziness and/or syncope unrelated to posture or activity with prompt
recovery suggests an intermittent cardiac rhythm disturbance.
A4
Poor vision: Snellen chart to assess visual acuity, examination of eyes for common causes of visual loss in elderly
people, i.e. refractive disorder, cataracts, glaucoma, macular degeneration.
Postural hypotension: lying and standing BP.
Neurological disorders: thorough central nervous system (CNS) examination essential. Focal UMN signs suggestive of
stroke or subdural haematoma. Upgoing plantar responses, consistent with cervical myelopathy; peripheral neuropathy
and posterior column dysfunction (joint position/vibration sense), suggest vitamin B12 deficiency.
Arthritis/osteomalacia: joint examination, back pain, muscle weakness.
A5
The following tests are necessary:
Lying and standing BP
ECG
Plasma urea and electrolytes (U&Es) and glucose
Full blood count (FBC) (and vitamin B12/folate levels if macrocytic anaemia present)
Radiograph of painful bones/significantly arthritic joints
Calcium, albumin and ALP (osteomalacia).
Thyroid function tests

Falls 141
Other tests might be indicated after preliminary assessment and investigation:
Cervical spine radiograph
Computed tomography (CT) of the brain.
A6
Vision: occupational therapist home visit to remove environmental hazards and improve lighting, assess for spectacles,
ophthalmic referral as needed.
Postural hypotension/polypharmacy: review need for and doses of all medications.
Neurological dysfunction: B12 replacement if deficiency, consider neurosurgical intervention if indicated (subdural
haematoma, cervical myelopathy).
Osteomalacia: calcium and vitamin D supplements.
AF: digoxin/amiodarone, etc. Bradyarrhythmia will require assessment for cardiac pacemaker.
CASE 6.3 – A 78-year-old man who lives alone is brought to A&E after being
found on the floor at home by his neighbour.
A1
Pneumonia
Dehydration
Parkinsonism
Head injury with intracranial bleed or contusion.
A2
Hypostatic pneumonia and dehydration often complicate a long period of immobility after a fall. Aspiration pneumonia
should also be considered.
Parkinsonism: the generalized muscle ‘cog-wheel’ rigidity is suggestive of parkinsonism. Reflexes can be difficult to elicit in
this situation. Spasticity caused by cerebrovascular disease would more usually be associated with hyperreflexia and
upgoing plantar responses. Parkinsonism might be a result of idiopathic Parkinson’s disease or secondary to other causes
such as medication (e.g. neuroleptics – haloperidol, risperidone, etc.). His unkempt state suggests a chronic insidious
decline before this acute presentation. Parkinson’s disease could present in this way.
Head injury is obvious on examination, but the severity is difficult to assess. A subdural haematoma (acute and/or chronic)
must be considered in this setting.
A3
Further history from family or neighbours, etc. is essential to establish the time course and pattern of his decline, as well as
any history of previous falls. An accurate medication history is required, from the GP’s records if necessary. Any suggestion
of alcohol abuse is important.
A4
Assessment of conscious level and airway is essential because he is at risk of airway obstruction and aspiration.
Signs of weight loss and/or lymphadenopathy (tuberculosis [TB]) as well as clubbing (bronchial carcinoma).
The rigidity of parkinsonism is usually of ‘lead-pipe’ or ‘cog-wheel’ type. A ‘pill-rolling’, resting tremor might also be
present.
Search for evidence of urinary outflow obstruction (enlarged bladder), faecal impaction (per rectum examination), bony
injuries (hip, skull) and pressure sores, which can be overlooked in this setting.
A5
Additional investigations:
Arterial oxygen saturation/blood gases
Blood and sputum cultures: pneumonia
Calcium: confusion caused by hypercalcaemia
ECG: arrhythmia
Radiographs of skull and sites of other apparent bony injuries
CT of head: acute or chronic subdural haematoma.
A6
Rehydration with monitoring of urine output

Falls 143
Oxygen therapy as directed by O2 saturation and/or arterial blood gas (ABG) measurements
Broad-spectrum antibiotics for hypostatic/aspiration pneumonia (e.g. benzylpenicillin, levofloxacin and metronidazole)
Discontinuation of any drugs likely to cause parkinsonism
If idiopathic Parkinson’s disease is suspected, gradual introduction of L-dopa-based medication once resuscitation
completed.

OSCE COUNSELLING CASE 6.1 – What advice would you give?
The daughter has a valid point, but you will need to explain that to prevent further fractures measures are needed to
reduce the risk of falling as well as a consideration of treatment for osteoporosis.
The patient would benefit from a multidisciplinary assessment in order to identify remediable medical illnesses that might
precipitate falls (e.g. cardiovascular disease, medications, poor eyesight, Parkinson’s disease). Advice from a physiotherapist
or occupational therapist on measures to enhance fitness and safety at home and to secure help if further falls supervene,
is also essential.
Osteoporosis can be assumed in this setting as a result of the presence of a low trauma fracture. Having excluded
secondary causes of osteoporosis (e.g. thyrotoxicosis, steroid therapy, multiple myeloma, hyperparathyroidism), treatment
for age-associated osteoporosis should be considered. In this setting calcium and vitamin D supplements are helpful and
relatively safe, although it is prudent to measure the plasma calcium level before and 6–8 weeks after initiating treatment.
A regular bisphosphonate is more controversial. The requirements for safe and effective oral dosing are somewhat
cumbersome and restricting and should be discussed carefully with the patient before initiating treatment.
OSCE COUNSELLING CASE 6.2 – A house-bound 94-year-old woman with epilepsy

(controlled with phenytoin) presents with falls,
weakness and generalized aches and pains.
A1
Osteomalacia.
A2
Lack of exposure to sunlight, poor diet if socially isolated and/or poor health, impaired metabolism of vitamin D as a result
of treatment with phenytoin (an enzyme inducer). Diseases causing malabsorption and chronic renal failure can also
predispose to osteomalacia.
A3
Proximal muscle weakness, bony tenderness (pseudofractures or Looser’s zones on radiograph), skeletal deformity such as
kyphosis and bowing of limbs. Significant hypocalcaemia can precipitate tetany with a positive Chvostek sign (spasm of the
facial muscles on tapping over the branches of the facial nerve in front of the ear) and Trousseau’s sign (spasm of the hand
and forearm muscles after compression of the forearm).
A4
Check blood level for 25-hydroxy-vitamin D and give vitamin D supplements either orally or intramuscularly. An adequate
calcium intake should also be provided, if necessary with oral calcium supplements (1 g/day).
Immobility 145
IMMOBILITY
? Questions for the clinical case scenarios given

Case 6.4
Q3: What additional features in the history would you seek to support the potential diagnoses?
Case 6.5
Q9: What are the likely causes of his immobility?
Q10: What can be done to improve his situation at home?
Case 6.6
Q12: In addition to regular medical and nursing attention, which members of the multidisciplinary team ought
to be involved with her care?
Q13: What medical complications might supervene during the next 4–6 weeks?
Clinical cases
CASE 6.4 – A 74-year-old man who has difficulty walking is referred to the
elderly medicine day hospital.
He is confined to his chair unless assisted to stand. He cannot get into bed at night. His past history includes neck surgery
for cervical spondylosis. He has hypertension treated with nifedipine.
He is obese, his legs are oedematous and he is incontinent of urine. He has ulceration and cellulitis affecting his lower legs.
CNS examination reveals normal cognition and cranial nerves, but weak arms and legs (power 4/5), brisk reflexes bilaterally
and upgoing plantar responses. His feet are warm but foot pulses are impossible to assess as a result of oedema.
CASE 6.5 – You have been called to see a 72-year-old man who lives alone at
home.
The district nurse has become increasingly concerned about his health. The patient has been house-bound for some time,
but is now unable to rise from his chair. He is a large man and his left hip is very painful. There is no history of a fall. He is
unkempt and his clothes smell of urine. He is a heavy smoker, and is breathless and wheezy with a chronic cough. His legs
are swollen and blistered. Detailed examination is difficult, but does reveal signs of airflow obstruction, cyanosis, elevated
JVP and peripheral oedema. Movement at the left hip is restricted and painful.
He is very reluctant to leave his home.

CASE 6.6 – A 68-year-old, previously active, woman is now unable to walk or

stand having sustained a stroke (right middle cerebral artery territory
infarction) 3 weeks previously.
She has a dense left hemiparesis, homonymous hemianopia and sensory disturbance. She is also dysphasic and has
difficulty swallowing. Recovery has been complicated by aspiration pneumonia. She has a urinary catheter and needs
regular toileting. She is in AF, BP 142/78 mmHg. She is reluctant to engage with her programme of rehabilitation.

OSCE COUNSELLING CASE 6.3 – A 75-year-old man who lives in a nursing home is
confined to his bed or chair as a result of a
previous left-sided stroke.
He is a large man and his care is made even more challenging as a result of the presence of dysphasia, dysphagia and mild
cognitive impairment. The patient’s GP periodically visits the nursing home to review his care and general condition.
List five important areas that the GP should enquire about or assess when visiting. Give a brief explanation as to why each
of these areas needs review.
OSCE COUNSELLING CASE 6.4 – A 65-year-old woman is reviewed in clinic following

recent colonic surgery.
Shortly after surgery she developed a hot swollen leg from a deep vein thrombosis (DVT), confirmed on duplex scanning.
She has been started on anticoagulation therapy.
She is upset that this developed and wants to you to explain why it occurred and what was done to prevent it.
How would you approach answering this woman?
OSCE COUNSELLING CASE 6.5 – The wife of an elderly man is distressed because
her husband’s attendance at the local elderly care
day hospital for physiotherapy has been
discontinued.
He unfortunately suffered a severe stroke 3 months ago and is now confined to a wheelchair. He has difficulty speaking as
a result of dysphasia.
What advice should be given?

Immobility 147
Key concepts
Many chronic diseases in older people present with difficulty walking or even transferring from chair to bed, etc. Immobility
itself is, of course, not a diagnosis but a symptom for which there might be any number of causes. Common illnesses in
older people, which impair walking, include:
Stroke disease
Osteoarthritis
Parkinsonism
Dementia
Visual impairment
Chronic cardiorespiratory disease
Injuries and complications of falling
Problems with feet and footwear.
Careful and accurate assessment is essential with the aim of identifying treatable causes so as to focus the efforts of the
multidisciplinary team. Remember that being immobile can lead to further disabling and potentially fatal complications
such as pressure sores, hypostatic pneumonia, DVT, osteoporosis, limb contractures, urinary retention and faecal impaction.
Answers
CASE 6.4 – A 74-year-old man who has difficulty walking is referred to the
elderly medicine day hospital.
A1
Cervical myelopathy
Gravitational and calcium antagonist-induced lower limb oedema
Infected leg ulcers
Possible DVTs.
A2
The history of neck surgery for arthritis and the finding of UMN signs in the arms and legs (with no evidence of
neurological dysfunction above the neck) is highly suggestive of cervical myelopathy consequent upon degenerative disease
of the cervical spine.
Impaired mobility, obesity and dependency of the lower legs will predispose to venous stasis, oedema and ulceration (and
in due course infection). This is a potent setting for venous thrombosis. Calcium antagonists can exacerbate peripheral
oedema caused by venous dilatation.
Urinary incontinence is inevitable in this setting owing to immobility and impaired bladder control caused by compression
of the cervical spinal cord.
A3
History of neck trauma or injury or arthritic symptoms with acute-on-chronic deterioration requiring neurosurgical
intervention.
Constipation: common in this setting and exacerbated by calcium antagonists.
History of previous venous thrombosis or peripheral vascular disease (PVD).
Symptoms of breathlessness or chest pain (pulmonary embolism [PE]).

Immobility 149
A4
Signs of PE or heart failure
Pressure sores (buttocks, sacrum, heels)
Faecal impaction and urinary retention
A5
Full blood count (FBC): infection
Renal function and plasma glucose: renal failure and diabetes mellitus
Urinalysis:
– heavy proteinuria if oedema caused by nephrotic syndrome
– glycosuria
– protein and blood consistent with urinary infection
Midstream specimen of urine (MSU): infection
Leg ulcer swab and blood cultures: to guide antibiotic therapy
Venous and arterial Doppler studies of legs: detection of venous thrombosis and exclusion of ischaemic leg ulceration
Cervical spine radiograph: cervical spondylosis/osteoarthritis
Magnetic resonance imaging (MRI) of cervical spine: to detect spinal cord compression
Chest radiograph and ECG: heart failure and pulmonary embolism.
A6
Neck surgery for cervical myelopathy is unlikely to be successful in this setting as a result of chronicity of symptoms.
Surgery could also be very hazardous as a result of significant co-morbidity.
Elevation of legs to diminish oedema.
Antibiotics for cellulitis.
Compression bandaging or hosiery to control peripheral oedema once cellulitis has resolved and arterial ischaemia
excluded.
Pressure relief mattress/cushion to areas at high risk of pressure sores.
Anticoagulant therapy if venous thrombosis confirmed (consider DVT prophylaxis if absent).

Discontinuation of calcium antagonist. Consider an alternative agent such as a diuretic (but might exacerbate
incontinence), an ACE inhibitor (might impair renal function) or a β blocker (care if heart failure/diabetes present).
Treatment for heart failure if confirmed.
Attention to bowel and bladder function.
Referral to multidisciplinary team for rehabilitation and resettlement at home in due course.
CASE 6.5 – You have been called to see a 72-year-old man who lives alone at
home.
A7
Basic investigations should include:
Hip radiograph essential: osteoarthritis or avascular necrosis of femoral head or fractured neck of femur
FBC: secondary polycythaemia, infection
Renal function tests: uraemia and electrolyte imbalance
Measurement of ABGs should be considered because of the signs of respiratory failure and possible hypercapnia
Chest radiograph and ECG: to support the diagnosis of chronic obstructive pulmonary disease (COPD) and cor
pulmonale
Peak expiratory flow rate (PEFR) and/or spirometry before and after inhaled bronchodilator will confirm COPD and
determine the degree of reversibility.
A8
Management is going to be difficult at home as a result of the need for radiographs and specialist tests, and the presence
of respiratory failure. Hospital admission is advisable in order to confirm the diagnoses and assess the degree of respiratory
failure. Time will be needed for rehabilitation and adaptations to the home environment.
Treatment will be along the following lines:
Analgesia for osteoarthritis (avoiding opiates and non-steroidal anti-inflammatory drugs [NSAIDs] if possible –
potential respiratory depression and fluid retention respectively)
Bronchodilators, controlled oxygen and cautious use of diuretics for COPD and cor pulmonale
Laxatives and enemas for faecal impaction/constipation
In due course, consideration of hip replacement if the patient is agreeable and cardiorespiratory status permits.
Immobility 151
Q9: What are the likely causes of his immobility?
A9
Osteoarthritic hip: a hip fracture is less likely as a result of the chronicity of the symptoms and absence of trauma.
COPD (chronic bronchitis and emphysema) and cor pulmonale.
Urinary incontinence caused by immobility is almost inevitable in this situation, perhaps exacerbated by coexisting
prostatism or faecal impaction.
Q10: What can be done to improve his situation at home?
A10
Much depends on the potential to improve and the feasibility of hip surgery. Even so, adaptations to the home with
appropriate seating and bedding, as well as a review of toilet and washing arrangements, will be necessary. His ability to
climb stairs safely will need to be assessed. He will need assistance with shopping and other household tasks. A
multidisciplinary team approach is required to resolve these various issues, including physiotherapy, occupational therapy
and social worker involvement. An early discharge might be achieved with forward planning and utilization of domiciliary
rehabilitation services.
CASE 6.6 – A 68-year-old, previously active, woman is now unable to walk or

stand having sustained a stroke (right middle cerebral artery territory
infarction) 3 weeks previously.
A11
Depression is common at this stage and can seriously interfere with rehabilitation. An antidepressant in conjunction with
psychological support and a positive approach by the multidisciplinary team can help alleviate this.
Anticoagulants: there is a risk of further stroke (12–15 per cent per annum), which can be reduced by two-thirds after
anticoagulation with warfarin (international normalized ratio [INR] 2.0–3.0).
Anti-embolic stocking: will help to diminish the risk of DVT and lower limb oedema.
Laxative: to prevent constipation.
Analgesia: pain and stiffness are common in this situation.
ACE inhibitor: if BP persistently > 140/80 mmHg (but be vigilant about the risk of precipitating symptomatic postural
hypotension in this setting).
Q12: In addition to regular medical and nursing attention, which members of the
multidisciplinary team ought to be involved with her care?
A12
Physiotherapist: to prevent contractures, maintain posture, avoid shoulder injury and improve function.
Occupational therapist: to promote independence and overcome functional impairments caused by motor, sensory and
visual impairments.
Speech and language therapist: including assessment and therapy to improve swallowing.
Dietitian: modification of diet to enhance safe swallowing and maintain adequate hydration and nutrition.
Stroke nurse specialist/psychologist: specialist advice, support and counselling to both patient and family.
Social worker: to explore any social issues relevant to a timely, safe and supported discharge from hospital.
Q13: What medical complications might supervene during the next 4–6 weeks?
A13
Painful shoulder caused by joint subluxation or capsular/rotator cuff injury (correct manual handling essential to
minimize this complication)
DVT/PE
Pneumonia (aspiration or hypostatic)
Urinary tract infection (UTI)
Faecal impaction
Pressure sores
Limb contactures
Depression
Post-stroke epilepsy
Recurrent stroke (haemorrhagic transformation or re-infarction).

Immobility 153

OSCE COUNSELLING CASE 6.3 – A 75-year-old man who lives in a nursing home is
confined to his bed or chair owing to a previous
left-sided stroke.
A1
Areas include the following:
SKIN CARE AND PRESSURE AREAS

Pressure sores (especially sacrum, hips and heels)
Intertrigo in skin folds such as groins, axillae and perineum
Leg ulcers complicating dependent oedema of the lower limbs
Soft tissue infections.
BLADDER AND BOWELS

Urinary incontinence is inevitable in this situation and will necessitate regular toileting and/or containment by pads, sheath
drainage or (as a last resort) urinary catheterization. Urinary catheter care will include regular catheter changes (3 to 4
monthly) to prevent encrustation, blockage and leakage.
Bowel function will need review. Faecal incontinence, constipation and faecal impaction with overflow diarrhoea might all
need appropriate management.
NUTRITION
Obesity will exacerbate nursing difficulties. On the other hand, difficulty swallowing, resulting in poor nutrition, might cause
weight loss. Provision of food and drink of appropriate consistency and manoeuvres to improve swallowing will need
discussion. Nutritional and vitamin supplementation might prove necessary. Liaison with dietitian and speech and language
therapist might also be helpful.
LIMB CONTRACTURES/OEDEMA
Flexion contractures of the limbs can develop over time and can be ameliorated to some extent by appropriate
positioning of the hemiplegic limb, as well as physiotherapy and anti-spasticity drugs such as baclofen.
Dependent oedema and DVT can develop in an immobile lower limb. Elastic hosiery can help to prevent this.
Shoulder pain can develop as a result of incorrect handling/lifting techniques.
RESPIRATORY COMPLICATIONS
Aspiration and/or hypostatic pneumonia.
MEDICATION REVIEW
The need for laxatives, analgesics, hypnotics and the appropriateness of medication for secondary stroke prevention
(aspirin, a statin, antihypertensives) will need periodic review.
SOCIAL AND PSYCHOLOGICAL WELL-BEING

Good quality care should encompass this important area too. Apathy and depression are common after a disabling stroke.
Boredom and isolation can lead to difficult behaviour. Regular visits from friends and family should be facilitated. Interest in
former hobbies and pursuits should be encouraged as far as is possible. Social activities, access to radio, TV, etc. are also
important, being mindful of the patient’s preferences and interests. Advice from a speech and language therapist will be
helpful in order to maximize communication.
OSCE COUNSELLING CASE 6.4 – A 65-year-old woman is reviewed in clinic after

recent colonic surgery.
The essence to this case is to discuss risk reduction and distinguish this from prevention. DVT is a well-recognized problem
post-surgery. The risk is higher in those with prothrombotic states (such as malignancy or a hypercoagulable syndrome, e.g.
factor V Lieden mutation) and where venous return may be compromised (pelvic surgery, lower limbs raised
intraoperatively, e.g. lithotomy position or with a pneumoperitoneum – laparoscopic surgery).
To try to prevent this, patients will be given a low-molecular-weight (LMW) heparin, are preoperatively well hydrated with
intravenous fluids (especially if they have had preoperative bowel preparation), will be wearing thromboembolic deterrent
stockings and may have been asked to stop any prothrombotic medication before surgery (e.g. tamoxifen). (LMW heparin
works by activating anti-thrombin III; it inhibits platelet aggregation and decreases the availability of thrombin. It has a
longer half-life than heparin and therefore requires only a single daily administration. The fact that its response is much
easier to predict removes the need for monitoring.) During surgery the legs are slightly elevated to aid venous return and
intermittent calf compression can be used. Post-surgery, early mobilization is encouraged.
Even with these precautions there is still a risk of a DVT developing. The importance of making the diagnosis and treating
appropriately should be emphasized.
If there has been an aberration to the normal protocols, increasing her risk, it should be admitted and a reason sought.
There is often a reason that can be explained (e.g. not giving heparin preoperatively if an epidural is to be inserted). Did the
preoperative consent discuss the risk of DVT?
OSCE COUNSELLING CASE 6.5 – The wife of an elderly man is distressed because
her husband’s attendance at the local elderly care
day hospital for physiotherapy has been
discontinued.
This is a difficult situation and the decision has probably been made because the patient is not making progress with
rehabilitation. A feeling of abandonment heightens the wife’s sense of distress at the withdrawal of therapy by the
multidisciplinary team. This situation can be avoided or ameliorated in a number of ways:
Setting clear goals for rehabilitation with realistic time scales that are understood by family/carers and when possible
the patient too.
Immobility 155
A graded reduction in therapy, transferring the emphasis of care into more socially oriented activities such as former
hobbies and interests
Ongoing support from a stroke nurse or another member of the multidisciplinary team such as social worker or home-
care assistant
Recognition of the needs of the carer. Attendance at the day hospital might have been a lifeline for the wife in terms
of providing regular respite from caring. Alternative arrangements such as a carer to sit with the patient at home or his
attendance at a local day centre or stroke club might be helpful.
ACUTE CONFUSIONAL STATES

Q1: List the most likely causes of his or her confusional state
Q2: What initial investigations should you perform?
Q3: What treatment would you consider appropriate?
Q4: The niece is worried about her aunt returning home alone at the conclusion of the hospital admission.
How would you address this concern? (Case 6.9 only)
Clinical cases
CASE 6.7 – You have been asked to see an 83-year-old man who has been
brought to A&E.
He lives in a residential home, and for the last 2 days he has become confused. He is not eating or drinking and his walking
has deteriorated. He has Parkinson’s disease, a history of angina and type 2 diabetes mellitus. His medication includes co-
beneldopa, selegiline, gliclazide, a nitrate preparation and aspirin.
On examination the significant findings are as follows:
Abbreviated mental test: 4/10; he is agitated and restless
His tongue is dry
BP 108/62 mmHg
HR 104/min regular
His chest is clear
Marked signs of parkinsonism (rigidity, tremor and bradykinesia)
Urinalysis: protein ++, blood +, glucose ++ and ketones negative.
CASE 6.8 – A 74-year-old man with a history of alcohol abuse was admitted to
hospital 24 hours ago after two witnessed epileptic seizures.
He recovered fully and was initially lucid, but is now very restless and agitated. He seems to be hallucinating. Examination
is difficult. He has a low-grade fever, and is tremulous and sweating. There are no obvious focal neurological signs. He is
not jaundiced or anaemic. BP 178/84 mmHg; HR 106/min, AF.
CASE 6.9 – An 84-year-old woman is found wandering in the street at night by

the neighbours and is brought to hospital.
She is very disorientated and confused. She is alert, but restless and agitated. She is convinced that she is late for work. A
telephone call to her niece confirms that the patient has been somewhat confused and forgetful for the last 9 months or
so. Further enquiry reveals that she needs help with her household and financial affairs. She has never wandered before.
Examination discloses AF (126/min), cardiomegaly, mitral incompetence and peripheral oedema. Her feet are in a state of
neglect and there is an infected bunion. Abbreviated mental test is 4/10. There are no focal neurological signs. The
remainder of the examination is unremarkable. Q3 is not applicable in this case.

OSCE COUNSELLING CASE 6.6 – What advice should be given to the matron of a
local nursing home who telephones the local GP
reporting that one of her elderly residents, who has
Alzheimer’s disease, has become
uncharacteristically agitated and restless?
OSCE COUNSELLING CASE 6.7 – An 84-year-old woman has been brought to A&E
having been found wandering at night.
She is alert but confused (Mini-Mental State Examination [MMSE] 12/30 (normal 27+/30). There are no focal neurological
signs, but she is cold (core temperature 35.5ºC). She is unable to give a coherent history. You telephone her daughter to
gain more historical information.
List five key aspects of the history that you need to establish in discussion with the daughter.
Key concepts
In order to work through the core clinical cases in this section, you will need to understand the following key concepts.
Acute confusion or delirium is a syndrome not a diagnosis and can be the mode of presentation of almost any illness,
especially in elderly people. The most important question is ‘why?’ There is great danger (for lack of collateral history) in
assuming that the patient has ‘always been like this’ or even that only one factor is involved. Always search for multiple
pathology.
Common precipitating factors include:
Infections
Metabolic disturbances (e.g. hypo- or hyperglycaemia, dehydration, electrolyte imbalance, uraemia, hypothermia)
Hypoxia and/or heart failure
Pain or injury
Surgery and anaesthesia
Drugs (especially anticholinergic, dopaminergic or opiate therapy and alcohol/tranquillizer withdrawal states)
Sensory overload (e.g. unfamiliar surroundings or situations)
Pre-existing cognitive impairment (often mild and previously unnoticed) or sensory impairment (deafness and/or poor
vision) is a common predisposing factor in older people, producing an ‘acute-on-chronic’ confusional state.
The cornerstone of management is to detect and correct the underlying causes as well as general measures to re-orientate
and reassure the patient. Sedation should be considered only when agitation/confusion is preventing essential tests or
treatment, the patient’s behaviour poses a danger to him- or herself or others, or it is necessary to relieve severe distress in
an agitated patient. The maxim ‘start low and go slow’ when prescribing for older patients is particularly germane in this
setting.
Answers
CASE 6.7 – You have been asked to see an 83-year-old man who has been
brought to A&E.
Q1: List the most likely causes of his confusional state
A1
His confusional state is multifactorial. Precipitating factors might include: UTI, dehydration and hyperglycaemia. Drugs,
selegiline (a monoamine oxidase type B inhibitor [MAOI-B]) and levodopa, (medications prescribed for treatment of
Parkinson’s disease) can also precipitate confusion, particularly in susceptible patients, i.e. those with pre-existing cognitive
impairment. Other potential factors might include silent MI (hypotension and history of coronary artery disease) or stroke
(symptoms and signs difficult to elicit owing to confusion and agitation). Enquiry about falls and head injury (even trivial) is
important because of the potential for subdural haematoma.
A2
FBC: infection
Sepsis screen: urine and blood cultures as well as chest radiograph
Renal function tests: electrolyte imbalance and uraemia
Plasma glucose: to assess diabetic control
C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR): non-specific markers of an inflammatory or infective
process
ECG: MI
Arterial oxygen saturation: to identify hypoxaemia caused by cardiopulmonary disease.
A3
Rehydration (intravenous) and correction of electrolyte disturbance
Sliding scale insulin infusion for control of diabetes
Broad-spectrum antibiotic to cover UTI (after obtaining appropriate cultures)
Discontinue selegiline: this drug is more likely to precipitate confusion than L-dopa-based medications
Maintain co-beneldopa at the minimum dose required to control parkinsonian symptoms
General measures to reassure and re-orientate the patient

Prevention of falls and pressure sores
Avoid major tranquillizers (haloperidol, etc.), which, in the presence of Parkinson’s disease, might precipitate a severe
neuroleptic sensitivity reaction.
CASE 6.8 – A 74-year-old man with a history of alcohol abuse was admitted to
hospital 24 hours ago after two witnessed epileptic seizures.
Q1: List the most likely causes of his confusional state
A1.
Alcohol withdrawal causing delirium tremens is very likely given the time course of his confusional state. Hypoglycaemia
might also be present, given the history of alcohol abuse and the potential for liver disease.
Occult head injury should also be considered. Inebriated or fitting patients are at great risk of injury and will have little, if
any, recollection of the event. Older patients with alcohol abuse are particularly susceptible to subdural intracranial
bleeding as a result of the combined effects of trauma, cerebral atrophy and coagulopathy.
The history of seizures raises the possibility of an intracranial space-occupying lesion (e.g. subdural haematoma, tumour),
although either alcohol excess or withdrawal itself can precipitate seizures. Electrolyte imbalance, particularly
hyponatraemia (syndrome of inappropriate antidiuretic hormone secretion [SIADH]), must be considered in the setting of
head injury or intracranial space-occupying lesion.
Infection: pneumonia, meningitis, urine are all possibilities in this setting.
Liver encephalopathy is unlikely in the absence of jaundice.
A check for gastrointestinal bleeding (per rectum) is important (note sweating and tachycardia), although the elevated
BP mitigates against this.
A2
Capillary glucose: hypoglycaemia

Plasma U&Es: SIADH
Liver function tests (LFTs) and INR: liver damage and synthetic liver function
FBC: bleeding and infection
Blood cultures; urine dipstick and culture should be sent as soon as a sample can be obtained
Chest radiograph when feasible: pneumonia
Arterial oxygen saturation: hypoxia
CT of head: space-occupying lesion/bleeding
Lumbar puncture should be considered (meningitis?) if the above tests fail to identify a cause and there is no evidence of
space-occupying lesion, bleeding or raised intracranial pressure on CT of the brain and no coagulopathy.
A3
Delirium tremens is very likely and should be treated with a benzodiazepine (e.g. intravenous diazepam followed by oral
chlordiazepoxide) tapered over 3–4 days.
Intravenous thiamine is also advisable because malnourished individuals with alcohol problems are at risk of developing
Wernicke’s encephalopathy.
Intravenous glucose (50 mL 25 per cent dextrose i.v.) if hypoglycaemia is detected on capillary glucose reading (send
plasma sample to lab for confirmation, but do not delay treatment while awaiting result).
Once agitation and confusion have been controlled, careful clinical examination is needed to assess for other causes of
confusion as outlined above.
CASE 6.9 – An 84-year-old woman is found wandering in the street at night by

the neighbours and is brought to hospital.
Q1: List the most likely causes of her confusional state
A1
The history is very suggestive of an acute-on-chronic confusional state, the former precipitated by acute illness(es).
Underlying cognitive impairment as a result of early Alzheimer’s diseases is quite likely in this setting but must not be
assumed. A search for acute illnesses such as infection (urine, infected bunion, respiratory), side effects of medication, heart
failure and metabolic disturbance (diabetes, uraemia, etc.) is essential. She is wandering at night so hypothermia must be
considered.
In addition to an acute illness, causes of chronic confusion must be considered such as dementia (Alzheimer’s or vascular
brain disease), thyroid dysfunction, vitamin B12 deficiency and hypercalcaemia. If there is a poorly maintained gas appliance
at home, chronic CO poisoning might need to be excluded.
A2
FBC: anaemia, infection
Urinalysis and MSU: infection, diabetes
Blood cultures and swab e.g. from infected bunion
Plasma electrolytes, glucose and renal function: metabolic disturbance and uraemia
Calcium: confusion caused by hypercalcaemia
Thyroid function tests: often difficult to interpret in acute illness, but in this case important to exclude thyroid
dysfunction, particularly hyperthyroidism in view of AF and heart failure
Chest radiograph: infection, heart failure
ECG: to confirm AF
Arterial oxygen saturation (and spectrophotometry for carboxyhaemoglobin if CO poisoning suspected)
Once the acute illnesses have settled and if chronic confusion persists, CT of the brain should be considered to exclude
potentially treatable causes of chronic confusion such as hydrocephalus, meningioma and chronic subdural haematoma.
Vitamin B12 and folate levels are needed if there is macrocytic anaemia.
Q4: The niece is worried about her aunt returning home alone at the conclusion
of the hospital admission. How would you address this concern?
A4
This is a difficult issue and there is insufficient information provided to formulate an answer to this question. Once acute
confusion has settled cognitive and functional status should be reassessed by the multidisciplinary team (occupational
therapist and social worker, in particular). An old age psychiatry consultation might be required, particularly if dementia is
confirmed, so that an assessment of mental capacity can be made. If the patient insists on returning home alone, a
judgement about her capacity to assess the risk involved will be important. Assessment of the patient’s home environment
will also be important before a decision about discharge is finalized. Acetylcholinesterase inhibitor therapy, given to
enhance cognition, is contraindicated in this case because of cardiac disease.

OSCE COUNSELLING CASE 6.6 – What advice should be given to the matron of a
local nursing home who telephones the local GP
reporting that one of her elderly residents, who has
Alzheimer’s disease, has become
uncharacteristically agitated and restless?
This is a common scenario often referred to as an acute-on-chronic confusional state. Older people with impaired cognitive
reserve are at greater risk of delirium and this is often precipitated by events such as intercurrent illness (commonly
infection), an adverse reaction to medication, emotional distress or pain/discomfort. The first priority is to ensure the
patient’s safety while identifying and correcting the offending precipitant.
The nurses should check for symptoms and signs of common infections such as UTI (fever, dysuria, incontinence,
abnormalities on urinalysis) and respiratory infection (cough, wheezing, dyspnoea). The medication chart should be
reviewed to see whether there are any new medications or amended dosages. Physical distress resulting from urinary
retention, faecal impaction, pain from injury (any recent fall?) or emotional upset should be identified and corrected. If
there is any suspicion of underlying medical illness, a prompt medical assessment will be needed.
In the interim, the nurses should be advised to monitor the patient unobtrusively and enhance orientation by ensuring
adequate soft lighting, to ensure that any hearing aid is operational and that spectacles are worn. A calm, confident
approach is needed and the reassurance of a close family member or friend is helpful.
The nurses should be asked to watch the patient closely to prevent accidents and injury, while encouraging fluids to correct
or prevent dehydration.
It is likely that the confusional state will settle if the offending precipitant is identified and corrected, although it might take
a few days or sometimes longer for the older person to settle back to normal. In many instances a hospital admission (with
its attendant hazards to a frail older person) can be avoided, but this will require close cooperation of the doctor, nursing
staff and family/carers.
OSCE COUNSELLING CASE 6.7 – An 84-year-old woman has been brought to A&E
having been found wandering at night.
1. Duration of confusion
2. Systems enquiry
3. Previous medical history
4. Drug history
5. Social history.
DURATION OF CONFUSION
Is this an acute, acute-on-chronic or chronic confusional state? The first two conditions, i.e. acute or acute-on-chronic
confusion, warrant a diligent search for intercurrent general medical conditions that might have precipitated the current
delirious state (e.g. infection, CNS event such as head injury, metabolic disturbance, hypothyroidism). The latter condition,
i.e. chronic confusion (duration > 6 months), is more consistent with a dementing illness such as Alzheimer’s disease.
SYSTEMS ENQUIRY
The patient cannot give a coherent account of events, but while lucid might have previously reported important symptoms
to a close relative or carer. Enquiry along these lines might reveal, for example, a description of a recent head injury
(subdural haematoma), urinary symptoms (infection), thirst and urinary frequency (diabetes mellitus), or cold intolerance
(hypothyroidism), etc.
PREVIOUS MEDICAL HISTORY

This might give important information relevant to the current presentation, e.g. a history of liver disease, cerebrovascular
disease, chronic renal impairment or cardiopulmonary disease might cause or predispose to an acute confusional state.
DRUG HISTORY
Medications can commonly cause of confusion in older patients. Offending agents include: anticholinergics (e.g.
trihexyphenidyl for Parkinson’s disease), tricyclic antidepressants (e.g. amitriptyline), opiates, hypoglycaemic agents (e.g.
glibenclamide) and dopaminergic drugs (e.g. L-dopa). Alcohol should also be considered.
SOCIAL HISTORY
This information is essential in order to gain a proper understanding of the context of the presenting illness, potential for
rehabilitation and, in due course, discharge planning.
Incontinence 165
INCONTINENCE
Cases 6.10 and 6.11

Q1: What are the likely causes of the problem?
Q2: How should the problem be investigated?
Q3: What can be done to help?
Case 6.12
Q5: What treatments should be considered?
Q6: Suggest three reasons why the incontinence has gone unreported by the patient for so long
Clinical cases
CASE 6.10 – A 78-year-old woman, disabled by stroke, is cared for by her
daughter.
Care at home is proving difficult as a result of persistent urinary incontinence such that a nursing home placement is now
being considered. The patient has a left hemiparesis and dysphasia, and needs help to stand, transfer and walk. She
receives treatment with aspirin (for stroke), amlodipine (for hypertension) and furosemide (for swollen ankles).
The patient is alert and responsive, but has difficulty communicating as a result of her dysphasia. Sometimes she is able to
indicate that the lavatory is needed, but is usually wet before toileting can be achieved.
In addition to the signs of stroke, examination shows an excoriated perineum. There is no palpable bladder. Rectal
examination is normal. There is no uterovaginal prolapse.
CASE 6.11 – An 82-year-old man with advanced Parkinson’s disease and

dementia is cared for in a nursing home.
His nursing needs are usually fairly predictable. Of late, he has become more agitated than usual. He seems uncomfortable
and has started to shout and rattle the bedsides, and occasionally he hits out at the nurses. The on-call GP has prescribed a
sedative to settle the patient at night. He is continuously wet with urine and, unusually for him, is now incontinent of liquid
faeces too. He has no fever and other vital signs are normal.
CASE 6.12 – A 90-year-old woman who lives alone has slipped and fallen in her
bathroom at home.
She has escaped serious injury. Subsequent visits by the district nurse to assess the situation reveal that the elderly
woman’s clothing is always soaked in urine and the house has a strong smell of urine. The patient is reluctant to discuss
the situation but does admit to a swelling ‘down below’. She is sensible and independent in her activities of daily living.
She is reluctant to be examined by the nurse, but in due course assessment reveals a swelling at the vaginal introitus,
which on further examination is shown to be the cervix. When the patient stands up she leaks urine. Her bowel function is
normal.
There are no other abnormal findings. In particular there is no palpable bladder, neurological examination is normal and
urinalysis is negative.

OSCE COUNSELLING CASE 6.8 – An elderly hypertensive woman is attending the
surgery for regular assessment of her BP.
On this occasion her daughter attends as well and mentions that the family is very concerned about the patient’s apparent
incontinence of urine. The daughter goes on to say that her mother’s house and clothing have now developed a constant
smell of urine. On direct questioning the patient makes light of this problem. She seems sensible.
How would you proceed?
OSCE COUNSELLING CASE 6.9 – An 86-year-old woman is distressed by persistent

incontinence of urine.
Outline the key steps to establishing the cause of this problem in a primary care setting.
Key concepts
Urinary incontinence to some degree is common in elderly people, affecting about 12 per cent of men and 20 per cent of
women aged 65 and over, compared with 1 per cent and 6 per cent of those aged 15–64 years. Transient causes include
confusional states, immobility, urine infection, diabetes, stroke, retention with overflow and drugs. Incontinence can persist
if the above conditions remain unresolved. Established incontinence can also occur in many other chronic disorders.
Examples include: unstable bladder resulting from detrusor instability (urge incontinence), pelvic floor incompetence (stress
incontinence), neurogenic bladder (e.g. spinal cord lesions, cerebrovascular disease), as well as incontinence associated
with dementia, prostatism, bladder tumour or stone, and of course immobility from any cause.
Assessment must include a full history and examination, including per rectum and (if appropriate) per vaginam, as well as
CNS and locomotor assessments. Investigations include urinalysis, MSU, U&Es, glucose, calcium, plain abdominal
radiograph and/or ultrasonography and, in selected patients, urodynamic studies.
Accurate diagnosis and treatment are essential. Effective treatments for urge incontinence include bladder retraining and
drugs to stabilize the bladder (e.g. anticholinergics such as oxybutynin and tolterodine), but side effects can be problematic
in elderly people. Stress incontinence can be helped by pelvic exercises to strengthen the pelvic floor as well as surgical
suspension procedures. Devices to ameliorate incontinence (pads, sheath drainage, urinals, intermittent self-catheterization)
are effective to varying degrees and are appropriate steps to avoid permanent catheterization with its attendant hazards
(infection, soreness, bypassing, etc.).
Incontinence 167
Faecal incontinence is less frequent than urinary incontinence, but can be more distressing to the patient and carers.
Community-based studies reveal a 2 per cent prevalence of faecal incontinence in people aged over 65 years, rising to
about 25 per cent in the over-85-year age group. Prevalence rates in nursing homes and hospital is even higher. In a British
study, only half those reporting faecal incontinence had discussed this with a health-care professional. Causes include
underlying diseases in the rectum or anus (e.g. tumour), faecal impaction with overflow diarrhoea (secondary to immobility
caused by, for example, stroke or arthritis), neurological disorders affecting sphincter control (similar to those causing
urinary incontinence) and cognitive disorders such as dementia or severe depression. Once again accurate diagnosis and
treatment of remedial factors are essential (e.g. enemas for faecal impaction). When remedial measures fail or are
inappropriate, faecal incontinence can be controlled by means of a drug-induced constipation regimen alternating with
periodic planned bowel evacuation by enema or suppository.
Answers
CASE 6.10 – A 78-year-old woman, disabled by stroke, is cared for by her
daughter.
A1
In this situation there are several factors responsible for the urinary incontinence:
Damage to the CNS by a stroke will have impaired the central capacity to inhibit bladder (detrusor) contractions,
resulting in frequency and urgency of micturition.
Immobility as well as difficulty calling for help and perhaps cognitive dysfunction will precipitate urinary incontinence.
Diuretic therapy will exacerbate the need to pass urine quickly.
Immobility and incomplete bladder emptying both predispose to UTIs which can also cause incontinence.
A2
Urinalysis and MSU: to assess for infection, diabetes or occult renal disease
U&Es: hypokalaemia, hyponatraemia and renal failure
Plasma glucose: polyuria caused by hyperglycaemia
FBC: infection.
A3
Discontinue the diuretic and observe. There is no history or signs of heart failure. Ankle swelling is a common side
effect of calcium antagonist medication such as amlodipine. If this can be withdrawn, diuretic therapy might no longer
be required. Persisting hypertension might be better managed by a β blocker or ACE inhibitor. In this situation, elastic
hosiery is a more appropriate method for controlling dependent oedema.
Assess communication and cognition with the help of a speech and language therapist. Try to improve the patient’s
ability to communicate the need to pass urine (bell, picture card, gestures, etc.).
There should be an assessment of the home environment and toilet facilities by an occupational therapist. Techniques
to allow clothing to be removed quickly, assistance with transfers as well as equipment to facilitate toileting
(commode, grab rails, raised toilet seat, etc.) will promote continence.
Incontinence 169
District nurse and carer to work with the patient to establish a regular toileting regimen so as to anticipate and thus
prevent incontinence. Pads and barrier cream are needed to protect the perineum.
Antibiotics if UTI confirmed.
If the above measures prove insufficient, consider stabilization of the bladder with anticholinergic medication, e.g.
tolterodine or oxybutynin. Such treatment needs to be used with caution because of predictable anticholinergic side
effects (confusion, glaucoma, constipation, dry mouth, etc.).
Finally, assistance with toileting and washing at home from the home-care service and regular monitoring of the
situation by the district nursing team. Regular respite care should be considered to sustain the daughter in her caring
role.
CASE 6.11 – An 82-year-old man with advanced Parkinson’s disease and

dementia is cared for in a nursing home.
A1
Urinary and faecal incontinence are not uncommon in the setting of dementia and relative immobility caused by conditions
such as Parkinson’s disease. Nevertheless, regular toileting and maintenance of a daily bowel habit by appropriate diet,
simple laxatives and, when necessary, suppositories, are usually sufficient to maintain control of this situation. In this
scenario, it is very likely that faecal impaction has supervened with overflow of liquid stool. This is a most uncomfortable
situation for the elderly man who is unable, as a result of confusion, to draw attention to his predicament. Urinary retention
with overflow of urine is also very common in this setting, particularly if there is pre-existing urinary outflow obstruction as
a result of prostatic enlargement. Anticholinergic drugs, sometimes used (inappropriately) in older patients with Parkinson’s
disease, and opiate-based analgesics can also precipitate this problem.
Urinary infection is not infrequent in this setting, but would usually be associated with fever and offensive urine. Infective
diarrhoea would tend to produce profuse liquid stool associated with fever and dehydration and there might also be other
affected residents in the home. Clostridium difficile enteritis should be considered if the patient has recently received a
broad-spectrum antibiotic.
A2
A careful clinical examination (even if difficult) is essential, with particular reference to fever, hydration, bladder
enlargement (often non-tender in chronic retention) and rectal examination (prostatic enlargement and/or impaction
with hard stool).
Urinalysis and, if appropriate, stool culture for evidence of infection.
Plasma U&Es should be sent if obstructive uropathy or dehydration is suspected.

A3
Faecal impaction should be relieved by regular enemas, with attention to regular bowel care as outlined in A1. Once
constipation is relieved, urinary retention might resolve spontaneously – especially if the patient is able to sit or stand to
pass urine. Failing this, temporary urinary catheterization (with measurement of residual urine to confirm the diagnosis)
should be performed until the bowel function has normalized. Anticholinergic- and/or opiate-based medication should be
withdrawn. Treatment for UTIs should be guided by antibiotic therapy. Infectious diarrhoea will require ‘barrier nursing’
precautions to prevent the spread of infection. C. difficile enteritis should respond to oral metronidazole or vancomycin.
CASE 6.12 – A 90-year-old woman who lives alone has slipped and fallen in her
bathroom at home.
A4
The patient has a third-degree uterine prolapse resulting in stress incontinence as a result of pelvic floor (sphincter)
incompetence. A history of leakage of urine when straining, coughing, laughing or even standing is usual. There is a
recognized relationship between stress incontinence and weakness of pelvic floor musculature and sphincter tone. Ageing,
oestrogen deficiency, previous multiparity and surgical interference at parturition are also predisposing factors.
Q5: What treatments should be considered?
A5
Lesser degrees of pelvic floor incompetence can be treated to good effect by pelvic floor exercises taught by a
physiotherapist, in conjunction with oestrogen replacement therapy. The situation described in this scenario requires
gynaecological referral and control of uterine descent by either pessary or surgery.
Q6: Suggest three reasons why the incontinence has gone unreported by the
patient for so long
A6
Incontinence is often unreported by older patients. Embarrassment, social isolation, and fear of investigation or treatment
and acceptance as ‘normal’ ageing or that ‘nothing can be done’ are all factors to a greater or lesser degree.
Incontinence 171

OSCE COUNSELLING CASE 6.8 – An elderly hypertensive woman is attending the
surgery for regular assessment of her BP.
Urinary incontinence is a common problem in old age and is often unreported. The reasons for this reluctance to seek
medical advice are multi-factorial and include embarrassment, a belief that nothing can be done or that it is an inevitable
consequence of ageing. Health-care professionals can also fail to enquire about this symptom or, if it is mentioned, may
feel unable to intervene in an effective manner.
The first step is to secure the patient’s confidence and trust. An approach by the practice nurse might be a more successful
first step in order to gain an initial history and preliminary assessment. It will be important for the nurse/doctor to
emphasize that assessment is relatively simple and that an effective treatment is very likely. Even if cure is not feasible,
improvement and/or containment of symptoms is certainly possible.
The initial assessment should include a thorough history and examination (note rectal and vaginal examinations), paying
particular attention to medications as well as any gynaecological and/or neurological symptoms and signs. Urinalysis, urine
culture and bladder scan (to assess bladder emptying and residual volume) are also essential steps in the assessment. Most
assessments can be completed in a general practice setting and measures instituted to improve the common conditions of
urge and stress incontinence. The advice of a continence nurse specialist is useful for the treatment of complex cases and
where a more detailed knowledge of containment devices and pads is required.
OSCE COUNSELLING CASE 6.9 – An 86-year-old woman is distressed by persistent

incontinence of urine.
KEY STEPS
The key steps include a full history focusing on:
Precipitating factors
Pattern of voiding, including assessment of frequency and volume
Previous as well as current medical and surgical illnesses, including obstetric procedures and problems
Drug history especially diuretics, anticholinergics, sedatives, opiates
Assessment of functional status and toileting arrangements
Corroborative details from carer/relative.
FULL EXAMINATION
Full examination focusing on:
Abdomen: for retention of urine, pelvic masses
Rectal examination: for constipation, tumour, anal tone
Vaginal examination: for prolapse, tumour, atrophic changes

Full neurological assessment: searching for evidence of cognitive dysfunction and other CNS diseases, such as stroke,
Parkinson’s disease, spinal cord disease, autonomic dysfunction.
Locomotor examination.
INVESTIGATIONS
Simple, focused investigations in response to the findings on history and examination, including:
Urinalysis
MSU
Measurement of residual volume (by catheterization or ultrasonography)
Capillary glucose
Plasma urea creatinine and electrolytes
Plain radiograph of kidneys, ureters and bladder (for renal/bladder stone).

7Respiratory medicine
Malcolm Shepherd and Neil C. Thomson
174 Respiratory medicine
DYSPNOEA

Q2: What issues in the given history support the diagnosis?
Q3: What additional features of the history would you seek to support a particular diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
Clinical cases
CASE 7.1 – Episodic breathlessness and wheeze.
A 35-year-old mother attends the medical outpatient clinic complaining of breathlessness with wheeze. This can occur at
rest and has been getting worse over the last 2 years. Between episodes of breathlessness she feels better but does not
feel that she ever returns to ‘normal’. Occasionally she awakens with shortness of breath and coughing in the early hours
of the morning.
CASE 7.2 – Chronic dyspnoea and cough.

A 66-year-old retired publican attends the respiratory outpatient clinic complaining of severe exercise limitation as a result
of breathlessness. He has trouble moving about the house and rarely goes outside. He feels worse in the mornings and
describes wheeze. His symptoms have developed over 3 years and his GP has tried inhalers but they have not helped. He
has had a cough with sputum for more than 10 years. He has been a smoker for more than 40 years and has smoked 5–10
cigarettes per day over this time.
CASE 7.3 – Progressive dyspnoea and weight loss.

A 66-year-old man presents complaining of worsening exercise tolerance as a result of breathlessness. He can walk 200
metres on a flat road whereas 1 year ago he could manage at least 1 mile. He also describes feeling short of breath at rest.
He is severely restricted on hills or stairways. He denies cough, but has lost 3 kg over the last 6 months. He is a life-long
non-smoker and worked in the ship-building industry where he was exposed to asbestos fibres. His GP describes inspiratory
crackles at both lung bases.
Dyspnoea 175

OSCE COUNSELLING CASE 7.1 – A 72-year-old man who suffers from cryptogenic
fibrosing alveolitis attends the clinic with his
daughter. They both feel that he requires oxygen to
help him with his daily activities.
A 72-year-old man who suffers from cryptogenic fibrosing alveolitis (CFA) attends the clinic with his daughter. They both
feel that he requires oxygen to help him with his daily activities.
Q1: What criteria should you assess before prescribing oxygen?
Q2: What advice would you give to him about the use of oxygen?
Key concepts
Spirometry
This is a useful test that is quick to perform and has good reproducibility. Spirometry measures the volume and velocity of a
forced exhalation over approximately 5 seconds. Two important values are derived. First, the volume of air expired in the
first second, known as the forced expiratory volume in 1 s (FEV1), and, second, the total volume exhaled in the 5 s, the
forced vital capacity (FVC). In the context of dyspnoea two patterns are frequently found. If both values are lower than
predicted for an individual’s size, age and gender, the pattern is described as a ‘restrictive pattern’ whereas if the FEV1 is
disproportionately smaller than the FVC, i.e. FEV1 /FVC ratio ≤ 75 per cent, the pattern is known as an ‘obstructive pattern’.
Answers
CASE 7.1 – Episodic breathlessness and wheeze.
A1
Asthma
Hyperventilation
Recurrent pulmonary embolism (PE).
A2
Episodic breathlessness, wheeze and cough with spontaneous resolution are typical of asthma. Symptoms tend to occur at
night, first thing in the morning or after exercise but none of these clinical features is specific for asthma. Progression over
2 years may suggest insufficient treatment of asthma.
A Q3: What additional features of the history would you seek to support a
particular diagnosis?
A3
A smoking history should be taken. It would be useful to assess likelihood of other associated atopic diseases by enquiring
about allergic rhinitis and eczema. Any environmental or other factors that exacerbate her breathlessness should be
identified, e.g. occupational asthma. A chronic cough without wheeze either currently or in the past may suggest cough
variant asthma.
A4
Examination is likely to be normal unless the patient is suffering from an exacerbation.
General examination should look for evidence of eczema, (dermatitis, ichthyoid skin). Respiratory examination may reveal
wheeze or hyperinflated lung fields.
Dyspnoea 177
A5
Peak expiratory flow (PEF): this is the most useful objective test to try to confirm a diagnosis of asthma. A 2-week
recording of the PEF measured twice a day can identify diurnal variation that is characteristic of asthma (≥ 20 per cent
from baseline). Specific but insensitive diagnostic test.
Spirometry: a single measurement may be normal or may demonstrate a low FEV1/FVC ratio (an obstructive pattern).
An improvement in FEV1 of > 15 per cent and 200 mL after inhalation of a bronchodilator or a 2-week course of
corticosteroid therapy is highly suggestive of asthma.
Chest radiograph: unhelpful in diagnosing asthma but may rule out alternative diagnoses or pneumothorax.
Full blood count (FBC): not useful although blood eosinophilia may occur occasionally in asthma
RAST (radioallergosorbent test), IgE to common allergens: these tests may identify specific agents to which the patient
is sensitive that could trigger asthmatic reactions. Common allergens include cat or dog hair, house-dust mite and
grass pollen.
A6
Assess asthma control: pattern and severity of symptoms and exacerbations, supplemented where appropriate with
serial PEF recording. An oral steroid trial (as above) may be required to demonstrate the patient’s best spirometry.
Eliminate trigger factors.
Patient education: ensure understanding of medications and how to alter treatment in the event of deterioration, and
check inhaler technique. Provide a written asthma action plan.
Stepwise drug treatment:
Step 1: mild intermittent asthma – inhaled short-acting β2 agonist as required.
Step 2: regular preventer therapy – add inhaled steroid 200–800 µg daily for patients with recent exacerbations,
nocturnal asthma or using short-acting β2 agonists more than once daily.
Step 3: add-on therapy – add inhaled long-acting β2 agonists agonist twice daily.
Step 4: persistent poor control – increase inhaled steroid dose up to 2000 µg daily, or consider trial of leukotriene
receptor antagonist, theophylline preparation or oral β agonist.
Step 5: continuous or frequent use of oral steroids – use daily steroid tablets in lowest dose tolerated.
CASE 7.2 – Chronic dyspnoea and cough.
A1
Chronic obstructive pulmonary disease (COPD)
Asthma
Bronchiectasis.
A2
Chronic progressive breathlessness on the background of a long smoking history suggests COPD. Typical features include
lack of spontaneous improvement or response to inhaled therapy, relentless progression of symptoms and a combination of
productive cough and dyspnoea. Although he has only a 20 pack-year smoking history, his occupation and the variable
effects of cigarette smoking make COPD the most likely diagnosis.
A3
A history of previous reversible wheeze and dyspnoea might suggest chronic asthma. Productive sputum can accompany
bronchiectasis and predisposing features should be sought, e.g. childhood infections. Assessment of severity in terms of
lifestyle and exercise impairment should be made. Chronic lung disease can precipitate depression and the patient’s mood
should be assessed because antidepressants can help.
A4
Physical examination is rarely diagnostic in COPD. Look for signs of respiratory failure (central cyanosis), hypercapnia
(bounding high-volume pulse, flapping tremor) and/or cor pulmonale (raised jugular venous pressure [JVP], ankle or sacral
oedema). Physical signs of airflow obstruction usually occur only when severe airflow obstruction is present, e.g. pursed
lipped breathing, hyperinflated thorax, paradoxical in-drawing of intercostal spaces, resonant percussion note, poor breath
sounds or wheeze.
Dyspnoea 179
A5
Spirometry: baseline spirometry with reversibility to bronchodilators should be performed in all patients suspected of
having COPD. The FEV1 is typically < 80 per cent of the predicted value, and the FEV1/FVC ratio is < 70 per cent; these
values do not return to normal with a bronchodilator. A short course of oral steroids can be used to help distinguish
chronic asthma from COPD. Post-bronchodilator FEV1 is used to classify the severity of COPD.
Chest radiograph: no specific features, but upper zone emphysema, hyperinflation (more than six ribs anteriorly), and
flattened diaphragm would support the diagnosis. It is useful to exclude an alternative diagnosis such as bronchial
carcinoma.
Arterial blood gases (ABGs)/pulse oximetry: measure in patients with severe disease; oxygen saturation ≤ 92 per cent
should lead to ABG measurement.
FBC: useful to exclude anaemia or polycythaemia.
α1-Anti-trypsin: may identify deficiency in rare cases; check in patients aged under 45 years.
A6
Aims of management: to lessen dyspnoea, reduce exacerbations and improve exercise tolerance with minimal side
effects.
Reduce risk factors: smoking cessation is the most effective way to reduce the risk of developing COPD and stop its
progression.
Bronchodilators: although no objective improvement in spirometry is seen in response to bronchodilator therapy in

COPD, patients may derive symptomatic benefit. They should therefore be provided with inhaled bronchodilators,
either a short-acting β2 agonist or anticholinergic therapy. Patients with more severe symptoms should be given a trial
with an inhaled long-acting β2 agonist or anticholinergic agent. Other agents may be tried on a symptomatic trial
basis, including oral theophyllines.
Inhaled steroids: result in small reductions in the frequency of exacerbation in severe COPD. Combination therapy of
an inhaled long-acting β2 agonist and an inhaled steroid may reduce the frequency of exacerbations more effectively
than either drug alone.
Oxygen therapy: long-term oxygen therapy is recommended for patients who have stopped smoking and who have
chronic respiratory failure (PaO2 < 7.3 kPa).
Pulmonary rehabilitation: useful to maximize patient functional capacity.
Immunization: against influenza yearly.
Depression: mood assessment should be made with intervention where appropriate.

CASE 7.3 – Progressive dyspnoea and weight loss.
A1
CFA
Pulmonary asbestosis
Cardiogenic pulmonary oedema.
A2
Progressive dyspnoea in a non-smoker with no history of cough may suggest fibrotic (interstitial) lung disease. Dyspnoea is
frequently first encountered on effort, but progression to dyspnoea at rest is common. The history of occupational exposure
to asbestos may suggest an industrial component to this disease, but formal diagnosis requires further investigations.
Crackles are typical of some forms of interstitial lung disease and are frequently confused with pulmonary oedema.
A3
An attempt should be made to quantify the degree of functional impairment experienced by the patient. The degree of
exposure to asbestos fibres should be enquired about. The history should also include information on any systemic disease,
drug therapy, travel and environmental exposures, e.g. agents known to cause extrinsic allergic alveolitis (EAA) such as bird
protein or mouldy hay. A history of ischaemic heart disease (IHD) or hypertension makes pulmonary oedema more likely.
A4
General examination should look for evidence of respiratory or cardiac failure. Ankle oedema, cyanosis, tachycardia and
respiratory rate should all be examined. Finger clubbing is frequently associated with CFA but less often in asbestosis.
Respiratory examination may reveal poor thoracic excursion, normal percussion note and widespread inspiratory crackles.
Weight loss frequently accompanies interstitial lung disease, but assessment for bronchial carcinoma should be made.
Dyspnoea 181
A5
Chest radiograph: may be normal or reveal shrunken lungs with coarse vascular markings (honeycomb lung) or patchy
areas of consolidation. Evidence of asbestos exposure may be found such as pleural calcification or plaques.
High-resolution computed tomography (HRCT): may reveal long-standing changes of fibrosis (honeycombing) or the
more acute changes associated with active inflammation (ground-glass intra-alveolar shadowing).
Pulmonary function tests: typically a ‘restrictive’ pattern of spirometry would be expected (FEV1/FVC ratio normal, but
both values less than predicted). Total lung volumes and static volumes are reduced and CO diffusion gradient is also
reduced.
Oxygen saturation/tension: it is useful to assess the degree of hypoxaemia, because this helps to quantify the severity
of disease and may indicate patients who will benefit from the administration of domiciliary oxygen therapy. A
6-minute walk test with SO2 (oxygen saturation) measurements is a sensitive test of early interstitial lung disease.
Serum markers of EAA: serum precipitins to avian proteins and other causes of EAA should be sought.
FBC: of little use although an elevated haematocrit may develop in response to chronic hypoxia.
Autoimmune antibodies: these may reveal the coexistence of connective tissue diseases that may present with
interstitial lung disease such as rheumatoid arthritis, systemic lupus erythematosus (SLE) or systemic sclerosis.
A6
General: patients should avoid any causal agents. Advice on seeking industrial compensation is appropriate in the case
of pulmonary asbestosis.
Drug treatment: controlling the progression of pulmonary fibrosis may be achieved in CFA by systemic corticosteroid
therapy or immunosuppressive treatment, although the response to treatment is often disappointing. Domiciliary
oxygen may be prescribed for patients with end-stage disease.

OSCE COUNSELLING CASE 7.1 – A 72-year-old man who suffers from CAF attends
the clinic with his daughter. They both feel that he
requires oxygen to help him with his daily
activities.
A1
SOCIAL CRITERIA
There is concern over the use of oxygen supplementation in the context of possible exposure to naked flame. Oxygen can
promote combustion and may make house fires more likely. It is recommended that patients who smoke are not prescribed
oxygen and that oxygen is not used in homes heated by open flame fires.
PATIENT CRITERIA
Assess requirement: patients with interstitial pulmonary disease may benefit from oxygen as a palliative measure at
later stages of the disease. The degree of alveolar hypoxia should be estimated by ABG measurement and the
secondary consequences of hypoxaemia should be assessed. If PaO2 is < 8 kPa and symptoms of dyspnoea are
disabling to the patient, oxygen may be prescribed on an ‘as required’ basis.
Assess capacity: oxygen is administered from either constant flow cylinders or from concentrators each of which must
be delivered to the patient’s home. The patient’s capacity to use the device should be assessed and where necessary
training or additional support from, for example, specialist nursing service should be arranged.
A2
There is concern over the safety of over-reliance on domiciliary oxygen. Patients should be advised that oxygen is safe in
stable respiratory disease, but that it is not a substitute for medical intervention in the event of a sudden deterioration.
Therefore if dyspnoea gets worse despite normal use of oxygen, medical advice should be sought.
There is concern about excess oxygen in COPD. Patients who have COPD may become dependent on hypoxic drive to
stimulate respiration, and COPD can complicate many respiratory conditions including fibrosing alveolitis. Although
supplementary oxygen is safe if properly assessed, increasing the supply of oxygen may depress respiratory drive. Patients
are advised not to make changes to the flow settings on their concentrators or cylinders, without seeking advice.
PLEURITIC CHEST PAIN

Clinical cases
CASE 7.4 – Sudden pleuritic chest pain and haemoptysis.
A 35-year-old woman is brought to the accident and emergency department (A&E) complaining of acute onset of chest
pain the preceding evening and collapsing that afternoon. She is shocked and dyspnoeic. This pain is described as ‘sharp’,
located posteriorly on the left hemithorax, and worse on inspiration and coughing. On the morning of admission there was
some haemoptysis. She has recently been in hospital for treatment and investigation of recurrent miscarriage.
CASE 7.5 – Gradual-onset pleuritic chest pain and haemoptysis.

A 73-year-old man attends his GP complaining of left-sided, ‘sharp’ chest pain. The pain is worse on inspiration, does not
radiate and has appeared in the last 2 days. He has not felt well for 1 week with uncontrollable shivering bouts and
sweats. He has had a cough with red-tinged sputum for 3 days. He smokes 20 cigarettes a day, and has angina
complicated by a myocardial infarction (MI) 2 years previously. He has recently felt increasingly short of breath with effort.
CASE 7.6 – Sudden pleuritic chest pain and dyspnoea.

A 30-year-old man attends A&E complaining of chest pain and breathlessness. The pain developed suddenly, 16 hours
before attendance, and he has gradually become increasingly short of breath since. The pain is described as sharp, worse
on inspiration or coughing, and located on the right thoracic chest wall. He denies new cough or sputum production.

OSCE COUNSELLING CASE 7.2 – A 35-year-old woman has completed 6 months of
anticoagulation therapy after having a life-
threatening pulmonary embolus. She now wonders
if she should consider oral contraception rather
than risk further pregnancy.
This 35-year-old woman was finally diagnosed as having a life-threatening PE. Having received 6 months of
anticoagulation therapy she returns to her doctor for advice. Her main concerns surround whether she should now consider
oral contraception rather than risk further pregnancy.
Q1: What risks exist and how should the GP advise her?
Key concepts
Pleuritic pain
This is pain usually localized to the thoracic wall, whose severity varies with respiration. Thus typically the pain will be
worse on inspiration and relieved by expiration. Commonly coughing exacerbates this type of pain. It normally derives from
inflamed layers of pleura moving over each other.
Thromboembolism
This is the passage of blood clots from a peripheral source to a more proximal vascular bed. Typically the origin of
thromboembolism is the deep veins of the leg and clots frequently lodge in the pulmonary arterial circulation.
Community-acquired pneumonia
This title distinguishes infective pneumonia that has developed in the community from those conditions that develop in a
hospital setting. These conditions are caused by different organisms and carry different prognoses.
Additional factors associated with pulmonary thromboembolism (PTE)
Pre-test probability (PTP) scores: these are designed to calculate the numerical risk of PE, based on clinical assessment, to
guide the interpretation of more detailed investigation. Such scores include the presence of tachypnoea (respiratory rate or
RR > 30), tachycardia, chest pain, clinical evidence of deep venous thrombosis (DVT), abnormal ECG (as a new finding) and
abnormal chest radiograph. The presence of one or more clinical feature plus one of the baseline investigations is said to
have a sensitivity for PE of > 80 per cent.
Additional features in community-acquired pneumonia
British Thoracic Society (BTS) guidelines: assessment of confusion (each question scores 1 mark, maximum score 10 marks):
Age
Date of birth
Time (nearest hour)
Year
Hospital name
Recall address (e.g. 24 West Street)
Date of First World War
Name of monarch
Count backwards from 20
Recognition of two people (e.g. doctor or nurse)
A score of 8 or less = mental confusion

Answers
CASE 7.4 – Sudden pleuritic chest pain and haemoptysis.
A1
PE
Community-acquired pneumonia with septic shock
Tension pneumothorax.
A2
Pleuritic chest pain with dyspnoea and haemoptysis is typical of PE. A recent spell in hospital where she may have been
relatively immobile and the history of recurrent miscarriages, which may be associated with thrombophilia, are potential
risk factors for PE. The sequence of a small embolic event followed by a more clinically significant episode with
haemodynamic compromise is typical of PE.
A3
Further enquiry should attempt to identify risk factors for DVT, e.g. smoking, history of DVT, PE or malignancy, recent long-
haul airline flight, family history of DVT or PE, and recent surgical procedures and use of DVT prophylaxis. A history of leg
swelling may indicate current DVT.
A4
The clinical presentation demands urgent emergency assessment and should follow the standard advanced life support
(ALS), ABC (A for airway, B for breathing and C for circulation) protocol.
Further clinical assessment should be aimed at identifying the presence of DVT and assessing the severity of respiratory and
haemodynamic compromise. Thus the respiratory rate, pulse rate, blood pressure (BP) and presence of cyanosis should be
recorded. Calves should be examined for swelling or tenderness and any circumferential differences should be measured
and documented. Detailed respiratory examination including auscultation, which may reveal localized wheeze, a pleural rub
or be normal, should be performed. A loud pulmonary second heart sound is rarely heard in acute PE.
A5
Chest radiograph: may be normal, show oligaemia or pleural-based wedge-shaped shadowing.
ECG: tachycardia, atrial fibrillation, rarely S1, Q3, T3 pattern.
Oxygenation: either saturation or PaO2 by arterial puncture is useful to assess severity.
Blood D-dimers: have high negative predictive value; measure only when there is a reasonable suspicion of PE.
CT pulmonary angiogram (CTPA): has replaced pulmonary angiogram as the imaging of choice.
Ventilation/perfusion isotope lung scan: normal scans reliably exclude PTE. Positive or negative scans are diagnostic in
between 30 and 50 per cent of cases, but rely on a normal chest radiograph appearance
Thrombophilia screen: important in this case given the history of recurrent miscarriage. Protein S, protein C, von
Willebrand’s factor, lupus anticoagulant and factor V Leiden should all be measured.
A6
Assessment: the initial management of this patient depends on the degree of haemodynamic compromise.
Immediate steps should be made to stabilize her condition, including supplementary oxygen therapy, intravenous fluid
resuscitation and transfer to a location where intensive monitoring can be performed.
If she remains haemodynamically unstable, thrombolytic therapy should be administered intravenously. Thrombolysis is
the first-line treatment for massive PE.
If the patient is stable: a pre-test probability of PE should be made before investigation and further management
should be directed by the likelihood of PE based on this PTP score and the appropriate investigations. If clinical
suspicion of PTE is high, full-dose anticoagulation should be initiated with low-molecular-weight (LMW) heparin, while
oral anticoagulant therapy (warfarin) is commenced at a loading regimen. Anticoagulation should be continued for a
minimum of 6 months and discontinued if there are no obvious predisposing factors remaining. Consideration to life-
long therapy should be made in the light of ongoing risk factors.
CASE 7.5 – Gradual-onset pleuritic chest pain and haemoptysis.
A1
Community-acquired streptococcal pneumonia
Community-acquired pneumonia caused by ‘atypical pathogen’
PE
Tuberculosis (TB).
A2
Symptoms typical of infection (fevers or sweats) with pleuritic chest pain suggest pneumonia; however, they can be
associated with PE. Although there are no clinical features specific for a given pathogen, Streptococcus pneumoniae
remains the most common cause of community-acquired pneumonia. The so-called ‘atypical’ pathogens such as
Mycoplasma species, Legionella pneumophila and Chlamydia species represent a substantial minority. In this patient, the
age, the presence of pleuritic chest pain and the cardiovascular co-morbidity are all associated with streptococcal
infections. The red-tinged or rusty sputum is said to typify streptococcal infections, but haemoptysis may occur with other
pulmonary infections, especially TB.
A3
Co-morbid conditions, associated with a poor outcome in community-acquired pneumonia should be sought, e.g. diabetes
mellitus, cystic fibrosis or chronic lung disease. If the patient has been bedridden or confused since the onset of symptoms
his prognosis is worse. It is very difficult reliably to determine the cause of pulmonary infections by history alone. Contact
with TB should be enquired after.
A4
Clinical examination in community-acquired pneumonia is directed at confirming the diagnosis and measuring a severity
score. The latter informs management decisions, including the best location for treatment (home, ward or intensive care
unit [ICU]), and the likely prognosis.
General examination should identify cachexia, pyrexia (the absence of fever in community-acquired pneumonia carries a
poor prognosis), cyanosis and peripheral lymphadenopathy, and the presence of labial herpes simplex. A Mini Mental State
Examination (MME) should be performed and recorded (a score of < 8/10 is associated with a poor prognosis). Respiratory
rate, pulse rate and BP should be recorded. Respiratory examination should look for the typical features of consolidation,
including dull percussion note, bronchial breathing, increased vocal fremitus and whispering pectoriloquy.
A5
Investigations are used to confirm the diagnosis and assess likely prognosis.
Chest radiograph: the most useful investigation in confirming the diagnosis. Unfortunately no single feature can
identify the causative organism. Multi-lobar involvement and/or pleural effusions are more frequent in bacteriological
pathogens and cavitation is more common with Staphlococcus aureus or Klebsiella pneumoniae infections. Multi-lobar
involvement carries a poor prognosis.
FBC: high leukocytosis (> 20 × 109/L) or leukopenia (< 4 × 109/L 9) carries a poor prognosis.
Urea and electrolytes (U&Es): a high urea has a worse prognosis and renal failure suggests severe sepsis.
Liver function tests (LFTs), creatine kinase: commonly abnormal in legionella infections.
Sputum culture: unless previous antibiotics have been administered.
Blood cultures and sensitivities: a very sensitive marker for aetiology if positive.
Serum for serology: paired samples for atypical serology
Urine and blood samples: for pathogen antigens.
A6
Assessment: initial management decisions should be informed by a severity assessment score. No such scores have been
fully validated, but the CURB-65 is commonly used. This score addresses confusion (described as an MMSE of < 8/10),
serum urea elevated > 7, RR > 30/min, abnormal BP (systolic < 90 mmHg, diastolic < 60 mmHg) and age > 65 years.
Community treatment is likely to be safe if none or one of these markers is present; the presence of two or more requires
hospital assessment and may require admission either to a ward or an ICU setting.
Treatment: medical treatment should include:
supplementary oxygen if required
the administration of intravenous fluids
the administration of antibiotic therapy.
Initially an empirical choice is required; however, this should not be delayed because the time to first dose of antibiotic
correlates with outcome. It is rare to have sufficient clues as to the identity of the infecting organism to guide initial choice.
In the UK most streptococcal infections remain sensitive to β-lactam antibiotics, whereas most atypical organisms are
sensitive to macrolides. It is reasonable therefore to prescribe co-amoxiclav and clarithromycin in the first instance, and
await sensitivities or treatment failure to guide further selection. In a hospital setting an initial intravenous dose and a
choice of intravenous or oral medication thereafter is frequently used. In the community both penicillin and macrolide
antibiotics are well absorbed orally.
CASE 7.6 – Sudden pleuritic chest pain and dyspnoea.
A1
Left-sided pneumothorax
PE.
A2
Sudden onset of chest pain suggests either trauma or spontaneous pneumothorax. As no history of a precipitating event is
given spontaneous pneumothorax is the most likely diagnosis. Frequently the pneumothorax will enlarge over time and
thus dyspnoea may develop relatively late. Pulmonary embolus should always be considered; however, there is no
supporting history given.
A3
The previous history of similar events is important because recurrent disease (even if not picked up clinically) is likely to
lead to further episodes and will usually be treated by a definitive procedure. Employment history is important because
professional diving or flying is banned after a pneumothorax. Recreational diving is also not recommended and should be
enquired about.
A4
Assessment of severity: ABC (A for airway, B for breathing and C for circulation). Occasionally pneumothoraces may
develop ‘tension’ and precipitate haemodynamic compromise. Cyanosis, tachycardia, hypotension and evidence of
mediastinal shift (away from the side of the chest pain) are indications of severity. Respiratory examination may reveal
tracheal shift (away from pneumothorax), hyperresonant percussion note on the side of the pneumothorax and normal
on the opposite side; reduced or normal breath sounds may be present.
Assessment for predisposing conditions: this should be made, e.g. Marfan’s syndrome may present with pneumothorax
and so it is worth examining arm span, palate and eyes for lens dislocation, and carefully for an ejection systolic
murmur.
A5
Chest radiograph: although, if clinical suspicion of tension pneumothorax is high, treatment should not await
radiological examination
Oxygenation: either saturation (if > 93 per cent) or ABGs
FBC: not useful in a pneumothorax
U&Es: not useful in a pneumothorax
Cardiac echocardiogram: if clinical suspicion of aortic incompetence (in Marfan’s syndrome).

A6
If haemodynamic compromise: immediate puncture of the chest wall in the second intercostal space anteriorly with a
large bore Venflon, releasing air from the pleural space. Attach a 50 mL syringe and a three-way tap after release of air
and perform underwater sealed aspiration of remaining air.
If no compromise and chest radiograph confirms the diagnosis: the first step is to perform aspiration under water seal.
If there is no obvious predisposing lung disease this should be sufficient to treat the pneumothorax. This procedure is
less likely to be successful if there is underlying disease such as COPD or bullous disease (secondary pneumothorax).
Failed aspiration or secondary pneumothorax: chest drain insertion and attached to underwater seal to allow the
gradual reinflation of the lung and removal of pleural gas. Administration of supplemental oxygen is said to hasten
reabsorption of pleural gas.
If a second or recurrent pneumothorax is present: a pleural sealing procedure should be performed such as talc
pleurodesis or video-assisted pleurectomy.

OSCE COUNSELLING CASE 7.2 – A 35-year-old woman has completed 6 months of
anticoagulation therapy after having a life-
threatening pulmonary embolus. She now wonders
if she should consider oral contraception rather
than risk further pregnancy.
Pulmonary embolus is a rare condition affecting between 1 and 4/1000 people in the UK per year. This risk is increased in
pregnant women tenfold over non-pregnant women. This risk is further increased if known risk factors coexist. Such risk
factors include age > 35 years, a thrombophilia, obesity (body mass index [BMI] > 30 kg/m2), paraplegia or inflammatory
bowel disease.
RISKS
In this case the history of life-threatening PE and recurrent miscarriage makes the presence of a thrombophilia more likely.
The precise risk depends on the nature of each thrombophilia. This patient carries three risk factors: age, history and a likely
thrombophilia.
Advice on further pregnancy: pre-pregnancy advice from a specialist should be sought. Extensive investigation of a
thrombophilia is important. Treatment with LMW heparin can be instituted throughout pregnancy, so investigation before
pregnancy is helpful.
Advice on contraception: the oestrogen content of the oral contraceptive pill is associated with a thrombotic risk. The
history of life-threatening PE contraindicates the oral contraceptive in this case and alternative methods should be used.
Haemoptysis 193
HAEMOPTYSIS

Clinical cases
CASE 7.7 – Two weeks of trivial haemoptysis and weight loss.
A 60-year-old man attends the medical outpatient clinic complaining of 4 weeks of cough productive of white sputum and
2 weeks of haemoptysis. The haemoptysis is described as ‘streaks of old blood through the spit’, and is trivial in volume. It
has remained constant throughout the 2-week period. There is no dyspnoea or chest pain, but he is a life-long smoker. He
has noticed his clothes being looser over the previous 6 months and describes a loss of appetite, but denies dysphagia or
altered bowel habit. He is easily tired and notices his voice becoming hoarse in the evenings. He is a bookmaker and is
married with two daughters, one of whom attends with him. She adds that her father appears slightly confused at times,
particularly in the evenings.
CASE 7.8 – Chronic cough and massive haemoptysis.

A 45-year-old mother of two presents at A&E on a Sunday night complaining of coughing large volumes of fresh red blood
for the last 2 days. She estimates that she has coughed up five mugs of fresh blood. She describes a cough with purulent
sputum for the last month, but cannot remember a time when she did not have a cough. She frequently receives antibiotics
from her GP when the sputum turns green or increases in volume. She has been increasingly breathless for the last 2
weeks, although she has noticed increasing breathlessness for 3 years
CASE 7.9 – Two months of fevers and haemoptysis.

A 62-year-old man attends the respiratory clinic complaining of worsening cough, spit and haemoptysis. This has been of 2
months’ duration and is associated with weight loss, anorexia, fevers, night sweats and purulent sputum. He denies chest
discomfort or dyspnoea. He lives alone, smokes 20 cigarettes per day and admits to drinking in excess of 40 units of
alcohol per week. As a child he was treated for TB at the same time as his father. He was a welder in a shipyard before
being made redundant.

OSCE COUNSELLING CASE 7.3 – A 65-year-old man, recently diagnosed as having
mycobacterium TB by sputum examination, is
brought to the chest clinic by his daughter.
She tells you that her father is an alcoholic and returns a large number of anti-TB tablets that have not been taken.
Q1: What are the risks of poor compliance with treatment in ‘open TB’?
Q2: What options are available to improve compliance?

Haemoptysis 195
Answers
CASE 7.7 – Two weeks of trivial haemoptysis and weight loss.
A1
Bronchial carcinoma
TB
Upper respiratory tract infection.
A2
Haemoptysis associated with weight loss suggests a systemic disease of uncertain duration. Bronchial carcinoma may
present late with haemoptysis after a lengthy period of weight loss and cough. Smoking is associated with most cases of
bronchial carcinoma and a non-smoking history should suggest other causes. Associated features of fatigue are non-
specific but frequently associated with pulmonary malignancy, whereas hoarseness and confusion should raise suspicions
about complications of the disease such as recurrent laryngeal nerve palsy or SIADH.
A3
Employment with a history of asbestos exposure may support pulmonary malignancy. The cumulative lifetime amount of
tobacco smoked should be noted, and the presence of constitutional features of fever and sweating may point towards an
infective origin of haemoptysis. Pain is an important complication of bronchial carcinoma and can be effectively palliated.
Thus, bone or chest wall pain (suggesting advanced disease) should specifically be addressed. An assessment of quality of
life and the World Health Organization’s ‘performance status’ is helpful to decide appropriate future management.
A4
Assessment of peripheral (hand – T1 root) muscle wasting, peripheral lymphadenopathy, hepatic enlargement and any
unusual or new skin lesions help to identify distant metastases. Finger clubbing is common, but non-specific. Respiratory
examination to identify lobar or lung collapse from a central obstructing tumour (tracheal deviation, apex beat, loss of
breath sounds) or pleural metastases (signs of effusion) is helpful for baseline assessment of the extent of disease. An
assessment of paraneoplastic syndromes can be helpful, e.g. blood pressure (autonomic neuropathy), skin rash
(pigmentation [ACTH] or dermatomyositis) or joint stiffness or discomfort (HPOA – hypertrophic pulmonary
osteoarthropathy).
A5
Chest radiograph: most important and may reveal diagnosis and complications.
Bronchoscopy with lavage or biopsy: important test to provide histology, particularly in central tumours.
Sputum cytology: largely unhelpful with only a 5 per cent sensitivity.
Computed tomography (CT): may identify non-carcinoma causes of haemoptysis, help staging and biopsy of peripheral
lesions seen on chest radiograph.
U&Es: helpful to exclude SIADH and assess fitness for treatment.
Serum calcium: elevated in some cases of bronchial carcinoma.
Liver function tests (LFTs): to help exclude liver metastases.

Pulmonary function tests: to assess fitness for thoracic surgery.
A6
Palliate symptoms: haemoptysis, pain and anxiety.
Treat underlying disease:
Small cell carcinoma: chemotherapy-based treatment. Either as palliation of symptoms (reduced dose) or with curative
intent (full dose). Cisplatin-based regimens are now the usual treatment option.
Non-small cell carcinoma: chemotherapy regimens are used only to downstage extensive disease and allow more
definitive therapy to be instituted. Such options include: surgical resection either pneumonectomy or lobectomy, and
radiotherapy, either radical or high-dose palliative.
Fully palliative radiotherapy for symptomatic control.
CASE 7.8 – Chronic cough and massive haemoptysis.
A1
Bronchiectasis
PE
Pulmonary TB.
Haemoptysis 197
A2
Chronic productive cough is a feature of bronchiectasis, which occasionally presents with massive haemoptysis. Chest
discomfort with haemoptysis may simply be associated with coughing-induced musculoskeletal discomfort, but PE should
be considered. A change in the volume or purulence of sputum associated with the constitutional features suggests chest
infection, which can herald haemoptysis in bronchiectasis.
A3
A history of a predisposing condition (childhood pneumonias, whooping cough or measles) should be sought but its
absence does not exclude bronchiectasis. Evidence of immunodeficiency might be suggested by recurrent infections outwith
the chest. A history of fertility problems, e.g. assisted conception, and bowel irregularities throughout life may suggest
cystic fibrosis.
A4
Initial cardiovascular examination to assess degree of blood loss, and thus pulse rate, BP, evidence of peripheral
circulation measured to exclude shock.
Respiratory examination, particularly crackles in any region of the lungs. Palpation of the painful region to confirm the
musculoskeletal nature of the pain. Finger clubbing is not present in most cases of bronchiectasis. Wheeze occurs in 75
per cent, crackles in 60 per cent.
A5
Chest radiograph: most important; in one series 20 per cent of cases of haemoptysis with a normal chest radiograph
had bronchiectasis.
Bronchoscopy: only if haemodynamically significant volumes of blood or to exclude bronchial carcinoma.
Sputum: helpful for microbiological identification especially Pseudomonas species.
HRCT: diagnostic investigation of choice with a 87–97 per cent sensitivity and 93–100 per cent specificity.
Bronchial angiography: helpful if radiological treatment of haemoptysis is warranted.
FBC: for assessment of anaemia.

A6
Resuscitation: if required
Antitussives: if severe and sometimes also sedation to control cough and anxiety
Treatment for infection: guided by sputum sensitivities
Managing haemoptysis: no specific treatment usually; if very severe and persistent consider bronchial artery
embolization or, as a last resort, surgical resection.
LONG-TERM MANAGEMENT
Bronchiectasis is a life-long condition that can result in chronic respiratory impairment. Patients should be warned that they
might deteriorate over time and require frequent courses of antibiotics. Physiotherapy for lung hygiene may be helpful to
reduce the frequency of infective exacerbations and preserve lung function. The evidence for the latter is currently lacking;
however, patients should be taught the appropriate exercises tailored to their own specific capacity. Patients should be
taught to look out for signs of infection, because prompt and appropriate antibiotic therapy may slow the decline in lung
function often associated with bronchiectasis. Specialist therapies may be tried in individual patients, including nebulized
antibiotic therapy or long-term rotational antibiotics (in which a series of antibiotics are chronically taken to keep bacterial
levels to a minimum with regular changes in the antibiotic to prevent drug resistance).
CASE 7.9 – Two months of fevers and haemoptysis.
A1
TB
Bronchial carcinoma
Pneumonia
Mycetoma
Bronchiectasis.
A2
A previous history of TB and the consumption of large quantities of alcohol suggest reactivation of old TB. The
constitutional symptoms support this diagnosis, but bronchial carcinoma should also be excluded in a smoker with
haemoptysis. Previous TB can give rise to mycetoma and bronchiectasis, both of which should be borne in mind. In case
series where bronchial carcinoma is rare or excluded, bronchiectasis and TB represent the greatest cause of haemoptysis.
Haemoptysis 199
A3
Contact with other people with similar symptoms should be ascertained, as should contact with close family. The type of
treatment used for the historical TB may suggest inadequate treatment.
A4
Clinical examination should attempt to exclude TB. Respiratory examination may suggest focal signs of old TB such as
crackles in the upper lobes, but may be normal in active TB. Evidence of liver disease should be sought given the alcohol
consumption and the possible need for anti-TB therapy.
A5
Chest radiograph: important
Sputum: three samples on different days for smears looking for AAFB and culture of organisms (for up to eight weeks)
Bronchoscopy: to exclude malignancy and allow bronchoalveolar lavage (BAL) and biopsy
U&Es: baseline
FBC: assesses anaemia
LFTs: baseline.
A6
Assess infectivity and risk:
Sputum for alcohol- and acid-fast bacilli is an urgent consideration
Likely contact with children or others. If high risk of contact spread admit for isolation until the sputum is negative for
organisms.
DRUG TREATMENT
Assess likelihood of multidrug-resistant (MDR) TB (HIV, foreign contact). If the patient is at high risk, institute quadruple
therapy; otherwise triple therapy with rifampicin, isoniazid and pyrazinamide (add ethambutol for quadruple therapy).
It is important in this case also to include pyridoxine and multi-B vitamins to reduce the peripheral neuropathic
complications of the anti-TB chemotherapy.
Assess compliance with therapy – if poor consider directly observed therapy (DOT).
Contact trace: likely contacts, family members, regular contacts.

Haemoptysis 201
OSCE Counselling Case – Answers

OSCE COUNSELLING CASE 7.3 – A 65-year-old man, recently diagnosed as having
mycobacterium TB by sputum examination, is
brought to the chest clinic by his daughter.
A1
Tuberculosis diagnosed by sputum examination is likely to be infectious. Although it may be safe to treat this man in the
community if his contacts are known, screened and limited, incomplete or no treatment increases the risk to the general
public of infectious spread. Before effective antibiotic treatment TB was a fatal disease and failure to take appropriate anti-
TB chemotherapy puts the patient’s own health at risk. Incomplete or intermittent treatment increases the risk of
developing drug-resistant TB. This can lead to chronic infection and the risk of community dissemination of MDR TB.
A2
Alcohol-related liver impairment may worsen the side-effect profile of some anti-TB drugs and may explain his poor
compliance. Such a problem should be sought and alternative drugs administered. Usually it is best to admit such a patient
to a ward or clinic and reintroduce regular triple therapy in a stepwise manner until the problem can be identified. It is
likely that this patient’s lifestyle is ‘chaotic’ and therefore regular compliance with treatment is likely to be poor. In these
circumstances DOT may be instituted. Directly observed therapy requires that a trained health-care professional, e.g. TB
specialist nurse or equivalent, visits the patient at a prearranged location either daily or on a three times a week basis and
observes the treatment being taken. Such practice has been found to reduce the incidence of drug-resistant TB in areas
with a relatively high prevalence. In very rare cases compulsory admission can be arranged under public health law. This can
be done only in the context of respiratory TB, where there is a considerable risk to the public health. Compulsory
administration of medications is not, however, permissible and it is therefore best to develop a concordant rather than a
coercive relationship with a patient.
8Gastroenterology
C.S. Probert
204 Gastroenterology
GASTROENTEROLOGICAL EMERGENCIES

Clinical cases
CASE 8.1 – A 73-year old man with melaena.
A 73-year-old man presents with a 5-day history of passing black stools. On the fifth day he began to feel breathless and
tired, particularly on climbing stairs.
CASE 8.2 – A 26-year old woman with bloody diarrhoea.

A 26-year-old woman presents with a 3-week history of bloody diarrhoea. The blood is fresh and mixed in the liquid stool.
Initially, she thought that she might have food poisoning, but could not recall eating anything unusual and had eaten the
same food as her unaffected partner.
CASE 8.3 – A 46-year-old man with alcohol problems and haematemesis.

A 46-year-old man with alcohol problems presents with haematemesis and shock.

OSCE COUNSELLING CASE 8.1 – Colitis, is it infectious?
You have determined that the woman in Case 8.2 has ulcerative colitis and tell her that you can treat it. She would like to
know whether she could have passed it onto the children in the school where she is a catering assistant.
OSCE COUNSELLING CASE 8.2 – Will my children get it (inflammatory bowel

disease)?
The same woman is also worried that she may pass it onto her own children.
Key concepts
Initial assessment of the cause of gastrointestinal (GI) emergencies such as bleeding or severe diarrhoea should be
carried out at the same time as resuscitation.
Most patients with haematemesis and/or melaena will have bled from a peptic ulcer, most cases of which are painless.
Proton pump inhibitor (PPI) therapy before endoscopic assessment is not evidence based.
Although stigmata of chronic liver disease may suggest varices as the cause of haematemesis, endoscopic assessment
should be made before ‘blind’ treatment using a Sengstaken–Blakemore tube.
Any form of colitis may be life threatening.
Infections should always be sought in parallel with resuscitation with intravenous fluids.
Answers
CASE 8.1 – A 73-year old man with melaena.
A1
The presence of black stools indicates GI bleeding above the ligament of Trietz. The likely sources include benign and
malignant ulceration of the stomach and peptic duodenal ulceration. The history should determine whether there are any
symptoms suggestive of ulceration, and risk factors and clues to whether the lesion is malignant. Postprandial and
nocturnal burning epigastric pains are classic symptoms of peptic ulceration, particularly if the pain radiates to the back.
However, these symptoms differentiate poorly between gastric and duodenal ulcers (20 per cent of patients with bleeding
peptic ulcers have ulcer-like dyspepsia). Risk factors to seek include:
Past history of peptic ulceration and/or surgery for such disease
Recent non-steroidal anti-inflammatory drug (NSAID) ingestion of any type. Warfarin and/or anti-platelet drugs
Smoking and alcohol
Diabetes
Heart failure.
The last three of these are likely to relate to poor mucosal healing. Clues to malignancy include weight loss, anorexia and
anaemia before the presenting gastrointestinal haemorrhage.
A2
The most likely diagnosis is a bleeding duodenal ulcer. It is unlikely that the patient is bleeding from an oesophageal lesion
(carcinoma or oesophagitis) because, in most cases, haematemesis will occur at the same time. Of all patients with acute
upper GI bleeding 40 per cent will have benign peptic ulcer disease. Duodenal ulcers appear to be more common than
gastric ulcers.
A3
A full physical examination is necessary with particular attention being paid to shock. However, in a patient of this age, a
systolic blood pressure (BP) of 110 mmHg may be considered to be shock. Of secondary importance is the examination of
the abdomen during which an epigastric mass and palpable liver should be sought.
A4
The first step in the management is resuscitation. The patient should be laid flat, given oxygen via a facemask while two
large-bore cannulae are inserted, one of which ought to be a central line if the patient is shocked. As the cannulae are
inserted, blood samples should be taken for full blood count (FBC), cross-match (4–6 units), urea and electrolytes (U&Es)
(as the urea is a marker of the amount of blood lost). Liver function tests (LFTs) are not of immediate importance. Clotting
abnormalities need to be sought if the patient is either taking warfarin or has jaundice. Fluid replacement should start as
soon as the cannulae are in place. There is no advantage to using colloids. Blood transfusion should start as soon as
possible if the patient is shocked or if he has a haemoglobin (Hb) ≤ 10 g/dL. A urinary catheter is desirable.
A5
Oesophagogastroduodenoscopy (endoscopy) should be performed within 24 h of admission. If the patient is shocked or

has Hb ≤ 10 g/dL, this should be performed as soon as the patient has been resuscitated, or immediately if urgent surgery
is contemplated (i.e. if resuscitation attempts are failing).
A6
The ulcer is likely to be Helicobacter pylori related. Triple therapy should be instituted. This is typically a PPI with two
antibiotics from amoxicillin, clarithromycin and metronidazole. If aspirin was being used, then clopidogrel may be
substituted.
CASE 8.2 – A 26-year-old woman with bloody diarrhoea.
A1
The duration of the disease suggests that the cause is acute colitis. The differential diagnoses include microbial diarrhoea –
Clostridium difficile (so a drug history is needed) – protozoa (a travel history should be taken), side effects of medications
such as NSAIDs, familial adenomatous polyps (the bleeding usually occurs in the context of normal stool – so a family
history should be taken). Lifestyle and past medical history should be considered in case the patient is
immunocompromised.
A2
The most likely diagnosis is acute colitis, most probably as a result of ulcerative colitis. Other forms of colitis caused by
Crohn’s colitis, drug side effects or C. difficile are possible. Cytomegalovirus (CMV) proctitis and amoebic dysentery are
unlikely.
A3
A full physical examination is necessary with particular attention to examination of the abdomen. Distension and
tenderness are particularly worrying physical signs in such a patient. Shock caused by colitis is uncommon, but critically
important. Anaemia and a fever should be sought. Severe colitis is defined by the presence of tachycardia, fever and
anaemia. Tenderness may indicate toxic dilatation or perforation.
A4
The patient may require admission or at least discussion with a senior colleague. Assuming that she meets the criteria for
admission, i.e. she has severe disease, the initial management includes bedrest, intravenous fluid replacement,
hydrocortisone 100 mg i.v. four times daily, transfusion to correct anaemia and nutritional support (typically high-energy
food cartons). Heparin is used in most centres: full anticoagulation may treat the disease, whereas prophylactic doses
prevent thromboembolism, to which such patients are prone. However, it is important to confirm the diagnosis rapidly. At
least three stool cultures should be taken. C. difficile toxin must be sought if antibiotics have been consumed recently.
Microscopy is often negative, but protozoa must be considered. A plain abdominal radiograph is necessary to assess the
diameter of the transverse colon and to look for the distribution of faeces, which may be used to determine disease extent.
A5
A limited sigmoidoscopy should be performed by a trained operator. This is a hazardous procedure in untrained hands.
However, assessment of the rectal mucosa often helps determine the aetiology of the colitis.
A6
The management of severe ulcerative colitis has two phases: control of the attack and maintenance of remission. If the
patient does not respond to intravenous hydrocortisone by the fifth day, a surgical opinion should be sought with a view to
colectomy on day 7. Any patient who deteriorates despite intravenous hydrocortisone should also be considered for
emergency colectomy. If hydrocortisone controls the attack, the patient should be weaned onto oral steroids and, probably,
a 5-acetylsalicylic acid (5-ASA) compound. Steroids should later be discontinued with a view to controlling remission with
the 5-ASA compound.
CASE 8.3 – A 46-year-old man with alcohol problems with haematemesis.
A1
This is bleeding oesophageal varices until proven otherwise. Although people with alcohol problems may bleed from all the
same lesions as those who do not have this problem, any of the former who has bled sufficiently to become shocked is
most likely to have varices. If the patient is shocked, treatment must be started before a full history is obtained. Indeed, the
patient may be unable to give a history. If a history is available, ask for previous episodes of GI bleeding and treatment for
varices.
A2
Bleeding oesophageal varices.
A3
Shock should be evaluated quickly: BP, heart rate (HR) and state of peripheral perfusion. Signs of portal hypertension would
support the diagnosis: ascites, spider naevi, umbilical hernia. Other evidence of decompensated liver disease should be
documented: Glasgow Coma Score (GCS), fetor, flapping tremor and bruising.
A4
The patient must be resuscitated as quickly as possible. The patient should be laid flat, given oxygen via a facemask while
two large-bore cannulae are inserted, one of which should be a central line. As the cannulae are inserted, blood samples
should be taken for FBC, cross-match (4–6 units), U&Es (as the urea is a marker of the amount of blood lost). Albumin and
clotting factors (prothrombin time, PT) can be measured to assess synthetic function: other tests, such as alanine
transaminase and alkaline phosphatase, assess hepatocyte damage and biliary tract disease/cholestasis, respectively.
Synthetic function is an important prognostic indicator. Fluid replacement should start as soon as the cannulae are in place.
The central venous pressure (CVP) should be monitored and blood and/or albumin given to maintain a pressure of 10–12
cmH2O. A urinary catheter is desirable. If the patient is in renal failure, despite an adequate CVP, call for senior help.
Vasopressin analogues are desirable, with senior guidance. If the patient remains shocked, a Sengstaken–Blakemore tube
may be necessary.
A5
Urgent endoscopy is both diagnostic and therapeutic. This should be performed as soon as the patient is cardiovascularly
stable. If such stability cannot be achieved, endoscopy may be performed while resuscitation is continued, provided that the
airway is protected.
A6
Broad-spectrum antibiotics should be given because bacteraemia is common at the time of variceal haemorrhage. Anti-
encephalopathy treatment (lactulose, metronidazole) should be started as soon as possible. IV thiamine should be replaced
before dextrose is given; without this there is a risk of precipitating Wernicke’s encephalopathy.

OSCE COUNSELLING CASE 8.1 – Colitis, is it infectious?
The answer is fortunately ‘no’. There are similarities, in the symptoms, between ulcerative colitis and infectious diarrhoea;
this is because some infections damage the colon and cause a different kind of colitis. However, infection (in her case) has
been ruled out by the stool tests. Furthermore, other tests (sigmoidoscopy ± biopsy) have shown that (her) symptoms are
caused by ulcerative colitis.
In the acute phase, most forms of colitis are very similar. Infection should be ruled out in new patients with acute disease.
Three sets of stool analysis are often necessary to exclude C. difficile with confidence. Campylobacter infection causes
acute colitis with bloody diarrhoea, but myalgia and abdominal pain are conspicuous.
Gastrointestinal infection may occur in patients with ulcerative colitis. Microbiological tests should be performed in patients
with an established diagnosis if the attack is atypical or refractory to the usual treatment.
OSCE COUNSELLING CASE 8.2 – Will my children get it (inflammatory bowel

disease)?
The answer is fortunately ‘no’. Although the disease can appear to run in families the risk is comparatively small. So the
chances of the children getting inflammatory bowel disease (IBD) are raised 10 times; the risk is still only 1 in 100, i.e. their
chances of getting IBD are less than their risk of diabetes or asthma.
This is an important test of communication skills. The key is to explain relative and absolute risks.
There is a genetic component to the risk of acquiring an IBD. The risk to first- degree relatives is 10–20 times greater than
that in unaffected families. However, this raises the prevalence only from 1 in 1000 to 1 in 100.
There is a wealth of literature describing genetic loci in IBD. Although few undergraduates will have read these, all should
be aware that loci have been described and that the disease is not sporadic, nor is there a simple mendelian inheritance.
PANCREATITIS

Clinical cases
CASE 8.4 – A 67-year-old woman with pale stools and weight loss.
A 67-year-old woman presented with diarrhoea. She describes her stools as pale. You discover that she has lost weight,
and has nocturia and thirst.
CASE 8.5 – A 26-year-old woman with abdominal pain and vomiting.

A 26-year-old woman presents with upper abdominal pain and vomiting. Previously she had experienced episodes of right
upper quadrant colicky pain that had lasted several hours at a time. On one of these occasions she had experienced a brief
episode of jaundice accompanied by dark urine. However, the present episode is different. The pain has lasted for 2 days
and appears to be worsening and, this time, it is non-colicky.
CASE 8.6 – A 48-year-old man with alcohol problems with chronic abdominal
pain.
A 48-year-old man with alcohol problems presents with upper abdominal pain with some radiation to the back.

OSCE COUNSELLING CASE 8.3 – ‘Why have I got pancreatitis?’
A 26-year-old woman with pancreatitis secondary to gallstones asks ‘Why have I got pancreatitis?’
OSCE COUNSELLING CASE 8.4 – ‘Why should I stop drinking?’

A 46-year-old man with alcohol problems presents with chronic relapsing pancreatitis asks ‘Why should I stop drinking?’
Pancreatitis 213
Key concepts
Acute pancreatitis is a significant cause of mortality. It should be considered in the differential diagnosis of all cases of
acute abdominal pain.
The diagnosis can generally be confirmed by an elevated serum amylase.
Risk factors for acute pancreatitis include alcohol abuse and gallstones.
Chronic pancreatitis, in general, has an insidious onset.
Presenting features arise from exocrine failure, later with endocrine failure, accompanied by epigastric pain that usually
radiates to the back.
Diagnosis is reached by assessment of exocrine function and/or imaging.

Answers
CASE 8.4 – A 67-year-old woman with pale stools and weight loss.
A1
The pale stool should prompt questions about malabsorption and/or obstructive jaundice. After asking about jaundice,
itching and dark urine – which should all be absent – direct questions to the stool. Look for fluffy, offensive, floating stools.
Blood and mucus will be absent. The duration of the symptoms should be noted along with exacerbating and relieving
factors. Abdominal pain should be sought – in particular epigastric pain. Such pain is unusual in coeliac disease (although
bloating is curiously common), but common in patients with chronic pancreatitis. With regard to the nocturia, assess the
volume (small amounts suggest a urinary tract infection [UTI], larger amounts suggest a diuresis – osmotic or drug
induced). Large-volume nocturia accompanied by thirst suggests diabetes or hypercalcaemia.
A2
The most likely diagnosis is chronic pancreatitis. This patient exhibits both exocrine and endocrine failure. Pain is absent in
50 per cent of older patients with chronic pancreatitis.
A3
A full physical examination is necessary with particular attention being paid to the state of nutrition and the cause of the
pancreatic failure. Alcoholism and haemochromatosis are associated with signs of liver disease and pigmentation,
respectively. However, most patients with alcohol problems have either liver or pancreatic damage. Alcoholism and
haemochromatosis are both associated with atrial fibrillation (AF) and cardiomyopathy. A per rectal examination should
confirm the colour of the stool.
A4
The first step in the management is to corroborate the clinical diagnosis. Blood samples should be taken for calcium,
glucose and urea. This will rapidly explain the source of the nocturia. Diabetes should be managed appropriately (see
Chapter 1). Early dietetic input should be obtained.
Pancreatitis 215
A5
The pancreas should be imaged and its exocrine function assessed. Imaging modalities to consider include: abdominal
radiograph (to show calcification – present in 30 per cent of cases), ultrasonography and computed tomography (CT). The
latter two have similar specificities (85–90 per cent), but CT is more sensitive than ultrasonography (75 per cent vs 65 per
cent). Exocrine function is currently best tested by the pancreolauryl test – which is non-invasive, cheap and easy to
perform. Faecal fats are no longer routinely available.
A6
After confirming the diagnosis, the diet should be modified – fats can be eaten and should not be avoided because the
patient will continue to lose weight. However, adequate pancreatic replacement therapy should be prescribed along with
acid-suppressing drugs. Pancreatic enzymes are usually buffered by bicarbonate secretion; however, in chronic pancreatitis
there may be too little bicarbonate so acid suppression is essential.
CASE 8.5 – A 26-year-old woman with abdominal pain and vomiting.
A1
Earlier episodes of right upper quadrant pain suggest biliary colic. The episode accompanied by jaundice and dark urine
suggests that a stone may have obstructed the common bile duct. The present problem suggests acute gallstone
pancreatitis. As with any abdominal pain, the site, radiation, and exacerbating and relieving factors should be sought. Acute
pancreatitis should always be considered in patients with acute abdominal pain.
A2
The most likely diagnosis is acute pancreatitis. The differential diagnosis for its aetiology is gallstone pancreatitis, hereditary
hypertriglyceridaemia and drug-induced pancreatitis. The differential diagnosis of the pain is cholecystitis, peptic ulcer
disease (≡ perforation) and Crohn’s disease.
A3
A full physical examination is necessary with particular attention being paid to the abdomen. Signs range from epigastric
tenderness to a full-blown acute abdomen with distension and rigidity. The Grey–Turner and Cullen signs should be sought.
An epigastric mass (pseudocyst) may be present. Shock may also be present.
A4
The first step in the management is to confirm the clinical diagnosis. Blood samples should be taken for amylase, calcium,
glucose and ‘blood gases’. Amylase is elevated threefold in most cases of acute pancreatitis; however, occasionally very
shocked patients have a normal amylase. Acidosis, hyperglycaemia and hypocalcaemia are all poor prognostic indicators.
The patient should receive analgesia (pethidine), an antiemetic, resuscitation with oxygen and intravenous fluids.
Hyperglycaemia should be corrected with an insulin infusion. Early senior review of patients who are shocked or have other
poor prognostic indicators is imperative.
A5
The pancreas should be imaged. Imaging modalities to consider include abdominal radiograph (to exclude a perforated
viscus and possibly to show a sentinel loop). Ultrasonography and CT are preferable. Ultrasonography is useful because it
can show gallstones as well as pancreatic necrosis; however, bowel gas may obscure the view. Computed tomography is
more accurate than ultrasonography for grading the pancreatic damage (90 per cent versus 73 per cent). Endoscopic
retrograde cholangiopancreatography (ERCP) has a role – primarily to treat the underlying pathology. Without intervention,
30–50 per cent of patients with gallstone pancreatitis have further episodes.
A6
After confirming the diagnosis, the patient should undergo supportive therapy. An underlying cause should be sought.
ERCP is recommended.
CASE 8.6 – A 48-year-old man with alcohol problems with chronic abdominal
pain.
A1
Epigastric pain may arise from pathology in three main sites: stomach/duodenum, gallbladder and pancreas. An accurate
description of the pain may help differentiate biliary colic from pancreatic and gastroduodenal pain – the latter two are not
colicky. Pancreatic pain tends to last for days or weeks rather than hours, as in the case of peptic ulceration. The
relationship to food and lack of relief with antacids, etc, should be sought.
Pancreatitis 217
A2
The most likely diagnosis is alcoholic chronic pancreatitis. Patients’ pain often precedes exocrine failure in people with
alcohol problems.
A3
A full physical examination is necessary with particular attention being paid to the abdomen and the nutritional status.
A4
The first step in the management is to confirm the clinical diagnosis. This can be problematic in the absence of exo- and
endocrine failure. The diagnosis is largely clinical, supported by anatomical changes when the pancreas is imaged and in
the absence of other pathology such as duodenal ulcer disease.
A5
The pancreas should be imaged. Imaging modalities to consider include: abdominal radiograph (to show calcification –
present in 30 per cent of cases), ultrasonography and CT. The latter have similar specificities (85–90 per cent), although CT
is more sensitive than ultrasonography (75 versus 65 per cent). Exocrine failure is not clinically apparent until 90 per cent
of the exocrine function has been lost. It is currently best tested by the Pancreolauryl test – which is non-invasive, cheap
and easy to perform. Faecal fats are no longer routinely available.
A6
After confirming the diagnosis, the patient should receive pain relief in line with the World Health Organization’s (WHO’s)
‘pain ladder’. Most patients require opiates and these should not be withheld because of concerns about their long-term
use. Of patients, 50 per cent respond to a nerve block. Surgery is seldom indicated.

OSCE COUNSELLING CASE 8.3 – ‘Why have I got pancreatitis?’
The answer is: ‘Unfortunately, your pancreas has become inflamed, this is called pancreatitis. The pancreas is an organ that
lies besides the gallbladder. Stones have grown in your gallbladder. One (or some) of these stones has passed into the tube
that links the gallbladder to the intestine. In this site, the same tube joins to the pancreas. As a result of the stone lying in
these tubes, the pancreas has become inflamed. Pancreatitis may also be caused by alcohol and drugs: there is no
suggestion that this is the case for you.’
This is an important test of communication skills. The key is to explain the anatomy of the biliary tree and how the
gallstones lead to pancreatitis.
It is important to explain that pancreatitis is a result of gallstones. As it can be a result of alcohol abuse, the patient should
be reassured that you understand that her pancreatitis is not so caused. The explanation of diseases that may, or may not,
be confused with those that are associated with social stigma require particular skill and tact.
Be prepared to discuss the management of any condition, the nature of which you have been asked to explain.
OSCE COUNSELLING CASE 8.4 – ‘Why should I stop drinking?’

The answer is ‘Your drinking has led to a serious disorder of your pancreas. This disorder may cause severe abdominal pain
and failure to digest your food (resulting in weight loss); if severe you may need surgery. In some patients it can be fatal. As
alcohol is the cause, it is important that you stop drinking in order to reduce of the risk of further severe attacks. If you
continue to drink the problem is likely to get worse. If you stop, the disease may not progress.’
In answering this question it is crucial to be both honest and understanding.
Patients may continue to have pain even if they do stop drinking. There is no place for blaming the patient if the pain
continues. Supportive measures should be offered.
Additional means of controlling the pain are likely to be called for including long-term analgesics, nerve blocks and even
surgery.
INFLAMMATORY BOWEL DISEASE

Clinical cases
CASE 8.7 – A 20-year old woman with ulcerative colitis.
A 20-year-old woman with ulcerative colitis has had symptoms for several weeks so she presents to the accident and
emergency department (A&E).
CASE 8.8 – An 18-year-old man with colicky, central, abdominal pain and
vomiting after meals.
An 18-year-old male smoker presents with colicky, central, abdominal pain and vomiting 30–60 min after meals. He had
been told that he may have IBD, but his mother is concerned because he has lost weight.
CASE 8.9 – A 21-year-old man with diarrhoea and a perianal abscess.

He has noted episodes of colicky lower abdominal pain over several months and it had been suggested that he may have
IBD.

OSCE COUNSELLING CASE 8.5 – ‘Will I get cancer?’
A 36-year-old man with established ulcerative colitis has heard that there is a risk of bowel cancer in patients with the
condition. He asks: ‘Will I get cancer?’
OSCE COUNSELLING CASE 8.6 – ‘Will I need to have the bag?’

A 20-year-woman old with refractory ulcerative colitis is concerned that surgery is imminent. She asks: ‘Will I need to have
the bag?’
Key concepts
Patients with IBD often present with symptoms that have been present for several weeks or months. Many will have been
told that they have IBS.
A history and examination will often point to the correct diagnosis by the time such patients present.
Patients should be counselled about the need for potentially embarrassing invasive investigations and the probable long-
term nature of IBD, and encouraged to seek help from reputable sources such as the National Association for Colitis and
Crohn’s Disease (NACC).
Answers
CASE 8.7 – A 20-year old woman with ulcerative colitis.
A1
The severity of the attack should be assessed. Specifically, the frequency and consistency of the stool should be assessed.
The presence of blood should be sought. The presence, periodicity and site of abdominal pain should be assessed, as
should any weight loss.
A2
Acute severe ulcerative colitis. The assessment of severity is based upon clinical observation. The differential diagnosis is
infectious diarrhoea and hypersensitivity to her treatment.
A3
A full physical examination is necessary with particular attention being paid to the signs of disease severity (fever, anaemia,
tachycardia) and to abdominal signs. Fever, anaemia and tachycardia define severe disease.
A4
The first step in the management is to corroborate the clinical diagnosis. Blood samples should be taken for FBC, C-reactive
protein (CRP) and albumin. A plain abdominal radiograph should be performed to assess colonic diameter as well as to
look for mucosal islands. Stool cultures should be performed. The patient should be admitted, commenced on intravenous
hydrocortisone 100 mg four times daily and heparin 5000 U s.c. three times daily. A stool chart should be commenced,
recording the frequency and amount of stool, and the presence of blood. Weight should be recorded.
A5
Senior review should be sought with a view to considering a cautious, limited sigmoidoscopy. Sigmoidoscopy is potentially
dangerous.
A6
If after 3–5 days the CRP and stool frequency have not improved, a surgical opinion should be sought with a view to
colectomy on day 7. Some centres recommend abdominal radiograph on alternate days. A deterioration in the abdominal
radiograph or the physical signs should prompt earlier surgical review.
CASE 8.8 – An 18-year-old man with colicky, central, abdominal pain and
vomiting after meals.
A1
The pain should be assessed, looking for site, radiation, and exacerbating and relieving factors, as well as special
precipitating factors – particularly foods. The frequency of the vomiting and its relationship to the pain (and meals) should
be clarified. The amount of weight lost should be documented and the duration of this symptom. A family and travel history
should be taken. Medication should be recorded.
A2
The symptoms suggest subacute obstruction. The differential diagnoses include adhesions, Crohn’s disease and
intussusception.
A3
A full physical examination is necessary with particular attention being paid to the nutritional state, signs of inflammatory
disease (fever, anaemia, tachycardia) and abdominal signs – specifically looking for a mass.
A4
The patient may warrant admission if he is malnourished, dehydrated or in pain. However, subacute obstruction is often
investigated as an outpatient. If admitted he will need: analgesia, intravenous fluid replacement (2–3 L/day) and a
nasogastric tube (to decompress the upper GI tract). Initial investigation of the admitted patient should include: abdominal
radiograph (for obstruction), U&Es, LFTs and FBC with CRP and plasma viscosity (PV). If not admitted, investigate as in the
answer below.
A5
After resuscitation (or in the outpatient setting), urgent barium follow-through (or small bowel enema) should be
performed. CT and/or ultrasonography may be indicated if there is a mass. CT will show the ‘pseudo-kidney sign’ if
intussusception is present.
A6
Subacute obstruction may be managed conservatively while the diagnosis is reached. Most cases come to surgery in the
long term.
CASE 8.9 – A 21-year-old man with diarrhoea and a perianal abscess.
A1
The diarrhoea should be assessed with regard to: frequency, duration, the presence of blood and mucus, and its
relationship to the abdominal pain. Constitutional symptoms – fever, and weight loss – should also be sought. With regard
to his abscess, duration of symptoms, and the site and radiation of the pain should be determined. Previous episodes and
their treatment should be recorded. Lifestyle, travel and a family history should be noted.
A2
The most likely diagnosis is Crohn’s disease. Diarrhoea need not be accompanied by blood in patients with Crohn’s disease.
Perianal abscess may accompany ulcerative colitis.
A3
A full physical examination is necessary with particular attention being paid to the abdomen, nutritional status, evidence of
systemic illness (fever, tachycardia, anaemia) and the perineum. Per rectal examination is not indicated because the abscess
encroaches on the anus. An examination under anaesthetic is preferred.
A4
The first steps in the management are to relieve suffering and confirm the clinical diagnosis. Pain should be relieved by
analgesia while a prompt surgical opinion is sought. Investigations to support the diagnosis should be performed with FBC,
LFTs, CRP and PV as a prelude to a surgical review.
A5
Generally, an examination under anaesthetic is the preferred approach to such patients. During this procedure, the abscess
may be drained, a sigmoidoscopy and rectal biopsy performed, and probing performed for a fistula. A stent may be placed
if the fistula is found.
A6
After managing the abscess, the diagnosis of Crohn’s disease should be confirmed. Imaging options include: magnetic
resonance imaging (MRI) and CT. MRI is the investigation of choice for imaging the soft tissues around the rectum and
demonstrating fistulas which usually underlie abscesses in Crohn’s disease. Crohn’s disease should be managed by draining
the abscess, seeking out and treating other foci of infection, and treating the disease itself.

OSCE COUNSELLING CASE 8.5 – ‘Will I get cancer?’
The answer is ‘There is an increased risk of bowel cancer in some patients with ulcerative colitis. This risk does not apply to
all patients. Young patients with extensive disease that has a grumbling course seem to be at greatest risk. The medication
that is given for the treatment of colitis (mesalazine) appears to lower the risk of bowel cancer. We will assess your risk by
plotting your disease extent. If the risk appears to be increased, we will discuss measures that may enable us to detect it at
an early stage. Although the risk to patients with ulcerative colitis of getting bowel cancer is greater than that of people
without colitis, the risk to an individual patient remains relatively small.’
It is important to be honest, but to offer reassurance at the same time.
Relative risk and absolute risk may be difficult concepts to explain to patients. It is worth planning your answer to such
common questions.
OSCE COUNSELLING CASE 8.6 – ‘Will I need to have the bag?’

The answer is ‘Yes, at least in the short term’. Patients with refractory disease are often taking steroids at the time of
surgery and so the surgery is kept as simple as possible. The operation of choice is to remove as much diseased bowel as
possible without operating deep in the pelvis. (A subtotal colectomy, oversewing the rectum above the levators.) A stoma
will be necessary. Most patients feel better very quickly and many soon adapt to the stoma. These patients will later need a
second operation to remove the rectum (a proctectomy). Other patients may prefer an ileoanal pouch. The pouch brings
about improved body image, but is associated with the need to pass stool frequently (typically four to six times a day). Of
patients, 15–20 per cent lose their bowel (undergo colectomy) in the long term.
It is important to differentiate the emergency situation in which the priority is to keep the patient alive and healthy, from
the elective situation where the aim is to restore quality of life.
Ileoanal pouches are not a panacea. The quality of life of patients with a pouch is only as good as that in patients with mild
ulcerative colitis. The stool of a patient with a pouch is likely to be loose and passed frequently.
Pouchitis with bloody looser stools occurs in 5–20 per cent of patients. It can often be managed medically, but may result
in a reversal of the pouch and recreation of the stoma.
PEPTIC ULCER DISEASE

Q2: What in the given history supports the diagnosis?
Q3: What additional features in the history would you seek to support a particular diagnosis?
Clinical cases
CASE 8.10 – ‘Doctor, I have indigestion.’
A 70-year-old man with arthritis and ischaemic heart disease presents with indigestion. He has epigastric pain radiating to
his back. He has been taking aspirin for his heart and ibuprofen for his arthritis.
CASE 8.11 – ‘Doctor, I have indigestion and cannot eat properly.’

A 35-year-old woman presents with a feeling of discomfort after eating meals. She describes a fullness after eating a
modest amount, and can no longer finish the meal that she used to eat. The indigestion is also troublesome.
CASE 8.12 – ‘Doctor, I am worried that I am losing weight and vomiting.’

A 60-year-old man is brought to see you accompanied by his wife. Together they describe that he has had progressively
worsening vomiting for some months. He has lost a stone in weight. He finds that the vomiting is worse after a full meal,
but liquids trouble him less than solid food. In the past he has suffered from indigestion and has taken over-the-counter
remedies for this.

OSCE COUNSELLING CASE 8.7 – ‘Can I take aspirin for my heart now that I have an
ulcer?’
OSCE COUNSELLING CASE 8.8 – ‘The tablets for my ulcer were wonderful. Should I
continue to take them?’
Key concepts
What is the aetiology of peptic ulcers?

Helicobacter pylori is found in > 90 per cent of patients with duodenal ulcers and 70 per cent of patients with gastric
ulcers. NSAIDs contribute to the aetiology of peptic ulcer disease. Smoking and alcohol are minor contributory factors.
How are they diagnosed?
The gold standard is the demonstration of an ulcer by endoscopy or barium meal. Endoscopy is preferable because gastric
ulcers can be biopsied, to look for malignancy, and H. pylori can be sought in the stomach of patients with peptic ulcers,
whether gastric or duodenal.
How are they treated?
As most ulcers are H. pylori related, H. pylori eradication should be prescribed. This consists of a PPI and two antibiotics
from metronidazole, amoxicillin and clarithromycin.
Answers
CASE 8.10 – ‘Doctor, I have indigestion.’
A1
Peptic ulcer disease
Carcinoma of the stomach
Carcinoma of the pancreas.
A2
Indigestion-like symptoms are usually a result of gastroduodenal disease. The diseases include mucosal inflammation
(gastritis, duodenitis) and ulceration. Most duodenal ulcer disease is associated with H. pylori; NSAIDs, including aspirin
and ibuprofen, enhance the risk of ulcer disease occurring in patients without H. pylori infection. This man is of an age
where ulcer-complicating H. pylori is quite common. His consumption of NSAIDs increases his risk.
A Q3: What additional features in the history would you seek to support a
A3
It is important to ask the patient about weight loss, because this may indicate that the patient has a carcinoma. His NSAID
medication should be reviewed. Evidence from his history of earlier ulcer symptoms before the current episode should be
sought.
A4
Full physical examination should be performed with particular attention paid to lymphadenopathy in the neck, which might
indicate metastatic disease from carcinoma of the stomach. The epigastrium should be examined with particular care for a
mass. The liver edge should be identified. An irregular edge might indicate a carcinoma.
A5
An endoscopy (oesophagogastroduodenoscopy) should be performed to look for peptic ulcer disease and to rule out
carcinoma of the stomach. Histology should be obtained for H. pylori.
A6
If the patient has H. pylori triple therapy should be prescribed followed by a long-term PPI to protect him against future
non-NSAID-associated risks. If he is H. pylori negative PPI drugs should be used alone. If the patient is found to have
carcinoma of the stomach, it should be staged and surgery considered. Patients with a gastric ulcer should undergo repeat
endoscopy after 6 weeks to ensure healing and to facilitate repeat biopsy to obtain further histological samples.
CASE 8.11 – ‘Doctor, I have indigestion and cannot eat properly.’
A1
Differential diagnosis is non-ulcer dyspepsia and peptic ulcer disease. Gastric cancer is very unlikely in a patient of this age.
The role of H. pylori in the absence of ulceration in such patients is not clear.
Early satiety (feeling fullness before completing a meal) is associated with non-ulcer dyspepsia. However, it may also occur
in patients with gastric outlet obstruction and carcinoma of the stomach. The patient’s age make these considerations
unlikely.
A2
Non-ulcer dyspepsia is a functional disorder often exacerbated by stress. Stressors should be investigated. The early satiety
means that non-ulcer dyspepsia is the most likely explanation although, if vomiting is present, carcinoma of the stomach
and/or other sinister pathology should be considered.
A3
It is important, in the history, to look for the patient’s ethnic background and family history, either of which might increase
the risk of peptic ulcer disease. Exposure to NSAIDs should be sought in the history – these may be over-the-counter
remedies. Consumption of alcohol and cigarettes should be investigated, although these are small contributory factors to
peptic ulcer disease compared with H. pylori.
A4
Full examination should be performed with consideration given to lymphadenopathy and epigastric mass. Such features are
not expected in patients with non-ulcer dyspepsia.
A5
It is useful to look for H. pylori in young patients with dyspepsia. There are several ways in which this can be conducted. H.
pylori can be identified by a urease breath test, necessitating a trip to the local hospital. H. pylori infection can be sought
using serology. Most GPs can perform this test and send the sample to a reference laboratory. Finally, endoscopy might be
used although, in a patient of this age, it is not usually indicated.
A6
Triple therapy may be prescribed for the patient if H. pylori positive: a PPI with two antibiotics from metronidazole,
amoxicillin and clarithromycin (typically one is metronidazole). It is important to stop PPI therapy after H. pylori has been
eradicated. Domperidone may also be prescribed to aid gastric emptying by increasing its motility.
CASE 8.12 – ‘Doctor, I am worried that I am losing weight and vomiting.’
A1
Pyloric stenosis secondary to H. pylori-associated peptic ulcer disease
Carcinoma of the stomach
Rare duodenal tumours, polyps, Crohn’s disease and dysmotility syndrome.
A2
The clue to the diagnosis in this patient is previous use of over-the-counter remedies for indigestion, mainly in a patient
with under-treated peptic ulcer. The vomiting suggests gastric outlet obstruction.
A3
Pyloric stenosis and carcinoma of the stomach may present in a similar manner.
Duodenal Crohn’s disease, polyps, etc. usually have a longer history. Dysmotility syndrome is unusual except in patients
with diabetes.
A4
On examination anaemia, lymphadenopathy, epigastric mass and irregular liver edge should be sought.
A5
Investigation is mandatory. Endoscopy and/or barium meal should be performed urgently. Computed tomography of the
upper abdomen should be considered. If these investigations are negative, gastric emptying studies should be performed.
A6
If the patient is found to have benign peptic stricture, endoscopic balloon dilatation should be considered. Surgery is called
for if balloon dilatation fails. If the patient has carcinoma staging should be performed and surgery considered. If the
patient has duodenal obstruction a gastroenterostomy should be performed. If the patient has dysmotility syndrome
domperidone or erythromycin should be prescribed.

OSCE COUNSELLING CASE 8.7 – ‘Can I take aspirin for my heart now that I have an
ulcer?’
In a patient who has a good indication for non-steroidal therapy such as coronary disease, transient ischaemic attack (TIA)
or inflammatory arthritis, aspirin and/or non-steroidal therapy should be resumed after the ulcer has been treated
appropriately, typically with triple therapy. PPI should be co-prescribed with the non-steroidal drugs. Consider alternative of
clopidogrel, which may be safer.
OSCE COUNSELLING CASE 8.8 – ‘The tablets for my ulcer were wonderful. Should I
continue to take them?’
The short answer to this patient is no. He should be told that the H. pylori infection caused the ulcer. Eradicating infection
will mean that the ulcer is unlikely to return. It is important to discontinue PPI therapy because of the problems of atrophic
gastritis, achlorhydria and bacterial overgrowth.
Cirrhosis 233
CIRRHOSIS

Clinical cases
CASE 8.13 – ‘Doctor, I have turned yellow and my stomach is swollen.’
A retired publican presents with progressive jaundice and abdominal swelling. He drinks more than 40 units of alcohol per
week. Previously he has been admitted with fever and vomiting, which he was told was caused by alcohol.
CASE 8.14 – ‘My husband has become confused.’

After several days in hospital, the patient with jaundice and ascites becomes confused, disorientated and aggressive.
CASE 8.15 – ‘Doctor, please see your patient. He is vomiting blood.’

A couple of days after showing evidence of encephalopathy, this patient with chronic liver disease has haematemesis.

OSCE COUNSELLING CASE 8.9 – ‘Should my husband have a transplant?’
OSCE COUNSELLING CASE 8.10 – ‘Why is my husband confused?’

Key concepts
How is decompensated liver disease recognized?
Decompensation is recognized from the following:

History: jaundice, abdominal swelling, drowsiness, GI bleeding
Examination: jaundice, fetor, flapping tremor, ascites, oedema, impaired consciousness
Laboratory investigations: poor synthetic function – falling albumin and prolonging clotting times.
How are bleeding varices managed?
First, by resuscitating with intravenous fluids – preferably blood products, and oxygen. Second, at endoscopy with a view to
injection sclerotherapy or band ligation. Finally, by Sengstaken tube placement and/or glypressin (intravenous).
How is ascites, caused by decompensated liver disease, managed?
First, ascitic fluid should be analysed for spontaneous bacterial peritonitis (SBP). If the white cell count (WCC) is > 250/mL
SBP is likely and should be treated with cephalosporins or ciprofloxacin. Second, therapy should be initiated:
Water restriction to < 1.5 L or even < 1 L/day with salt restriction
Spironolactone should be added starting at 50 mg with a slow increase in dose
Therapeutic paracentesis should be considered with intravenous replacement (100 ml 20 per cent human albumin
solution [HAS]) per 2–2.5 L ascites drained.
Cirrhosis 235
Answers
CASE 8.13 – ‘Doctor, I have turned yellow and my stomach is swollen.’
A1
Decompensated cirrhosis secondary to alcohol consumption or other causes of chronic liver disease.
Carcinoma of the pancreas (or similar upper GI cancer with liver metastases) and peritoneal spread.
A2
This man has a high-risk profession for alcoholic liver disease. His previous admission suggests that he may have had
alcoholic hepatitis. He is still drinking. The abdominal swelling is likely to be the result of ascites. Together the jaundice and
ascites indicate that he has decompensated cirrhosis.
A3
In the history it should be established whether he has been told that he has cirrhosis. Look for weight gain to support the
diagnosis of ascites (weight loss might indicate a malignant process). Swelling of the ankles would be common in cirrhosis
at this stage. Also history should be sought of previous ulcer disease that might indicate gastric cancer. Previous bowel
surgery might indicate a malignant process.
A4
The signs of decompensated alcoholic liver disease should be sought, including: Dupuytren’s contracture, palmar erythema,
spider naevi, gynaecomastia, hepatosplenomegaly and ascites.
A5
Ultrasonography of the abdomen with liver biopsy should be performed at an early stage. Paracentesis should be carried
out to look for a malignant process causing the ascites. The liver investigations will include hepatitis serology, autoimmune
profile, serum ferritin, α-fetoprotein, anti-trypsin and ceruloplasmin.
A6
The ascites should be treated with fluid restriction and spironolactone. If these measures do not work, paracentesis with
terlipressin and albumin (HAS) cover should be instituted.
CASE 8.14 – ‘My husband has become confused.’
A1
Encephalopathy secondary to decompensation, sepsis, electrolyte disturbance or GI bleeding.
A2
Patients admitted with decompensated liver disease are at high risk of encephalopathy. The instrumentation for
paracentesis may increase the risk of bacterial peritonitis. Venous access and urethral catheterization will increase the risk
of sepsis in those sites. Treatment of ascites might precipitate encephalopathy as a result of electrolyte disturbance.
A3
From his wife and the nurses, clues should be sought for the portal of entry of infection. The nurses should be asked
whether he has had haematemesis or melaena. Charts should be checked for undue diuresis.
A4
Full physical examination with a view to finding a focus of infection should be carried out. This must include the chest and
Venflon sites, and careful abdominal palpation. Rectal examination may be necessary to rule out melaena.
Cirrhosis 237
A5
Full septic screen should be performed with paracentesis, blood cultures, chest radiograph and urine cultures.
Electrolytes should be assessed. Hb might be measured to look for evidence of sepsis (raised WCC) and anaemia (indicating
GI bleed)
A6
The most likely explanation for the deterioration is sepsis. Cephalosporins and/or ciprofloxacin should be commenced.
Consideration should be given to staphylococcal infection. It will require gentamicin and/or flucloxacillin. If methicillin-
resistant Staphylococcus aureus (MRSA) is present, vancomycin may be used. Lactulose should be started immediately.
Neomycin, or more probably metronidazole, should be used to suppress bacterial growth within the bowel.
Electrolyte disturbance and hypoglycaemia should be corrected.
CASE 8.15 – ‘Doctor, please see your patient. He is vomiting blood.’
A1
Bleeding oesophageal varices
Bleeding peptic ulcer disease.
A2
Patients with decompensated liver disease are at high risk of variceal bleeding, having demonstrated evidence of portal
hypertension (through the ascites). Encephalopathy may have been precipitated by a GI bleed. Of patients with GI bleed on
the background of cirrhosis, 50 per cent actually bleed from non-variceal sources.
A3
No further features could be obtained in the history of this patient.

A4
Evidence of GI bleeding should be assessed, including observation of melaena and assessment of BP and pulse, and
sweating and anaemia should be sought.
A5
Urgent endoscopy should be performed with a view to finding and treating the varices. Full blood count is likely to show
anaemia, clotting tests (international normalized ratio [INR]) should be undertaken as well as a cross-match.
A6
At endoscopy (see above), banding and/or sclerotherapy should be used to stop variceal bleeding. Patients with peptic
ulcer haemorrhage should receive the preferred treatment in the unit. In most hospitals this is adrenaline (epinephrine)
injection.
Resuscitation with blood and/or clotting factors is mandatory. The treatment for encephalopathy should be continued and
possibly increased.
Cirrhosis 239

OSCE COUNSELLING CASE 8.9 – ‘Should my husband have a transplant?’
Liver transplantation is not indicated in patients who are still drinking alcohol. The consensus of opinion is that patients
should be abstinent from alcohol 6 months before surgery. In the 6 months between stopping drinking and surgery, full
liver support should be offered as well as psychological assessment.
OSCE COUNSELLING CASE 8.10 – ‘Why is my husband confused?’

Patients with liver disease become confused when the liver does not work properly. In this situation the risk of infection is
increased and chemical upsets now occur as part of the treatment. In addition, patients with this problem can bleed
internally. All of these factors lead to a disturbance of brain chemical function. However, in most patients this can be put
right.
CONSTIPATION

Clinical cases
CASE 8.16 – ‘Doctor, I can’t open my bowels.’
A 50-year-old man with squamous carcinoma of the bronchus and bony mestastases is referred complaining of abdominal
distension. He has not opened his bowels for 8 days. His abdominal pain has worsened and he has increased his morphine
sulphate tablets (MST), which previously he just took for bone pain.
CASE 8.17 – ‘Doctor, I don’t feel as though I empty my bowel.’

A teenage girl presents with abdominal discomfort and a story of passing pellet-like stools. She experiences abdominal
bloating before defecation and after defecation feels that she has not adequately emptied her bowels.
CASE 8.18 – ‘Doctor, please see this man with incontinence.’

A 78-year-old man with Parkinson’s disease is admitted from a nursing home with faecal incontinence. Previously he had
been noted to have stubborn bowels. Both he and the nurses were surprised when he began staining his clothing.

OSCE COUNSELLING CASE 8.9 – ‘Doctor, what can be done to stop my husband who
needs to take pain-killers becoming constipated
again?’
OSCE COUNSELLING CASE 8.10 – ‘Doctor, why can’t my daughter simply take senna
when she has constipation?’
Constipation 241
Key concepts
The aetiology of constipation
Constipation is a consequence of slow or interrupted transit through the intestine, in particular the large bowel. In most
patients it is a result of either drugs (anticholinergic side effects or opiates) or diet. Occasionally bowel motility is impaired
by hormonal or colonic neuromuscular disorders.
How is it managed?
A careful history should be obtained. Drugs causing constipation should be stopped or further drugs given to counter the
side effects. Diet should be improved, by the addition of fresh fruit and vegetables.
Answers
CASE 8.16 – ‘Doctor, I can’t open my bowels.’
A1
Opiate-induced constipation
Hypercalcaemia-induced constipation secondary to squamous carcinoma and/or bony metastases.
A2
Constipation is a symptom, not a disease. In this patient the risk factor for constipation is treatment with opiates. In
addition, patients with bony metastases and squamous carcinoma are at risk of hypercalcaemia. This needs to be
considered.
A3
It is important to see whether or not the patient appears dehydrated or confused which might suggest hypercalcaemia. In
the history it should also be determined whether the patient is taking laxatives while consuming MST.
A4
Look for evidence of dehydration that might accompany confusion, because this also indicates hypercalcaemia. This is an
insidious problem and should be specifically looked for on examination. The abdomen should be palpated and a rectal
examination performed
A5
The main investigations will include biochemistry for hypercalcaemia and uraemia. Abdominal examination might be
necessary to look for faecal loading if the patient had an empty rectum on physical examination.
Constipation 243
A6
Most patients will respond to enemas and stimulant laxatives, e.g. senna, accompanied also by softeners such as docusate
sodium. Co-danthromer is specifically indicated in patients with opiate-induced constipation in the terminal setting. If the
patient has hypercalcaemia, replace fluids intravenously and consider bisphosphonate treatment.
CASE 8.17 – ‘Doctor, I don’t feel as though I empty my bowel.’
A1
Poor dietary habit
Constipation-predominant irritable bowel syndrome (IBS)
Dysmotility.
( Myxoedema, hypercalcaemia and Hirschsprung’s disease are rare causes.)
A2
This girl is a prime candidate for poor dietary intake. Girls of this age can have fickle diets. Breakfast is often avoided. The
most likely explanation for her bowel disorder is poor dietary intake with an element of IBS.
A3
Full dietary history should be taken with particular attention to fruit, fibre and breakfast consumption. The history of stress
should be sought, as well as a history of sexual abuse, which is more prevalent in girls with IBS than other patients. If the
patient has vomiting or a family history, an underlying motility disorder might be the problem.
A4
On examination look for evidence of hypothyroidism, demonstrated by dry skin and goitre, perhaps with a bradycardia. On
examination of the abdomen, faecal loading should be sought. Rectal examination should be considered only after a
history of sexual abuse has been sought.
A5
Thyroid-stimulating hormone (TSH) and calcium may be measured, but in most patients it is unnecessary. Consider transit
time studies and full-thickness rectal biopsy.
A6
Dietary advice should be given with particular reference to fruit, fibre and breakfast consumption. It might be necessary to
add linseed, kiwi or other dietary laxatives to her diet. Regular medication (laxatives) should not be prescribed.
Occasionally a barium enema can be therapeutic as well as providing reassurance.
CASE 8.18 – ‘Doctor, please see this man with incontinence.’
A1
Overflow diarrhoea: secondary to medication, immobility, depression, colonic dysmotility.
Infections including norovirus, rotavirus and Clostridium difficile.
A2
Parkinson’s disease causes immobility, but can also cause smooth muscle dysfunction of the GI tract. Dysphagia and
constipation are common. The most common cause of faecal incontinence in this kind of patient is overflow diarrhoea.
A3
It is important to look for drugs that might contribute to constipation, including traditional anticholinergic medication for
Parkinson’s disease. His immobility should be assessed. Patients who are bed- or chair-bound have a greater risk of
constipation. Depression might also exacerbate immobility. It is not uncommon in people with Parkinson’s disease. In
addition, a source of infectious diarrhoea should be considered in a patient living in a nursing home.
Constipation 245
A4
Signs of Parkinson’s disease should be sought in addition to signs of faecal loading on abdominal and rectal examinations.
A5
If the patient has a loaded colon on physical examination, no investigation is called for. If the patient has an empty rectum
and no faecal loading on abdominal radiograph an infection screen should be performed.
A6
An enema followed by oral laxative should be prescribed to this patient. Consideration should be given to stopping
anticholinergic drugs and dealing with any depression.

OSCE COUNSELLING CASE 8.9 – ‘Doctor, what can be done to stop my husband who
needs to take pain-killers becoming constipated
again?’
Stimulant laxatives should be prescribed in all patients receiving opiate medication. The frequency and strength of the
laxative should match its strength. A prescription with such laxatives should prevent further problems.
OSCE COUNSELLING CASE 8.10 – ‘Doctor, why can’t my daughter simply take senna
when she has constipation?’
It is important to treat the cause of the constipation rather than the effect. Senna is a stimulant laxative that can lead to
problems later in life if started in such young patients. It is better to have a healthy, mixed diet to help with normal GI
function than to use laxatives.
Hepatitis 247
HEPATITIS

Clinical cases
CASE 8.19 – An 18-year-old student returning from India with jaundice.
An 18-year-old student has returned from a gap year spent in India with a short history of diarrhoea, abdominal discomfort
and jaundice.
CASE 8.20 – A 30-year-old ex-drug abuser presents with mildly abnormal LFTs.
A 30-year-old ex-drug abuser presents with feeling vaguely unwell. His GP has obtained liver function tests, but are mildly
abnormal with an alanine aminotransferase (ALT) of 50 IU/L (normal range < 40 IU/L).

OSCE COUNSELLING CASE 8.11 – ‘Doctor, I have given up my drug habit, but have
hepatitis C. Do I need to be treated?’
OSCE COUNSELLING CASE 8.12 – ‘Doctor, you told me I had hepatitis A. Is there a
risk that I will pass it on?’
Key concepts
Which forms of hepatitis become chronic?
Hepatitis B and C may both become chronic.

How is chronic viral hepatitis managed?
Treatment is determined by the grade and stage of liver disease (activity and fibrosis). In addition, the patient must have no
ongoing lifestyle risk factors for re-infection (i.e. not using intravenous drugs) or other forms of liver disease (i.e. not
alcoholic).
Hepatitis B: combination therapy with interferon-α and lamivudine is recommended.
Hepatitis C: combination therapy with pegylated interferon-α and ribavirin is recommended.

Hepatitis 249
Answers
CASE 8.19 – An 18-year-old student returning from India with jaundice.
A1
Hepatitis (A or B)
Amoebic abscess, Weil’s disease, side effect of medication, autoimmune hepatitis.
A2
The key to the diagnosis in this patient is the trip to India. Infectious (A) hepatitis is not uncommon in people returning
from this part of the world. The pain and jaundice make a hepatobiliary problem most likely. The patient is too young to
have gallstones unless she has a haemolytic disorder.
A3
In the history, attention should be paid to dark urine and pale stools, which might suggest cholestatic jaundice. If the
patient has abdominal pain, its site should be elicited. It is expected that hepatobiliary pain will be epigastric and right
upper quadrant in site. A history of dysentery should be sought; it might predispose the patient to amoebic liver abscess.
Drugs (medical and recreational) should be considered.
A4
Full examination should be performed including temperature, pulse, respiration and BP. The degree of jaundice should be
elicited. Anaemia should be sought. The size and texture of the liver should be found on examination. If the diaphragm
appears to be raised on the right side, consideration should be given to amoebic abscess.
A5
Hepatitis serology should be performed urgently (hepatitis A and B). Amoebic serology might be considered.
Ultrasonography of the liver should be performed to look for an abscess. Autoimmune profile should be obtained. LFTs,
FBC, INR and malaria screen should also be obtained.
A6
The treatment of hepatitis A and B is supportive. Weil’s disease is treated with penicillin-based antibiotics. Liver abscess
requires drainage and treatment of the underlying infection. Autoimmune hepatitis should be treated with steroids.
CASE 8.20 – A 30-year-old ex-drug abuser presents with mildly abnormal LFTs.
A1
Hepatitis C
Non-alcoholic steatohepatitis (NASH)
Hepatitis B.
A2
The patient’s lifestyle predisposes him to hepatitis B and C, particularly hepatitis C. Modest elevation of ALT is more
suggestive of hepatitis C than anything else. However, NASH can give a similar picture.
A3
Look for previous jaundice in the history that would suggest hepatitis B. If the patient is obese NASH is a possibility. A
history of alcohol consumption should be sought.
A4
On examination stigmata of chronic liver disease should be sought for patients with hepatitis. If there are no signs other
than simple obesity NASH is likely.
Hepatitis 251
A5
For hepatitis C, the investigations are serology (antibody to hepatitis C), polymerase chain reaction (PCR) for viral load,
followed by liver biopsy, preferably guided by ultrasonography. The hepatitis B serology and liver biopsy are required. For
NASH (hepatitis B- and C-negative patients), an ultrasonically guided liver biopsy should be obtained.
A6
If the patient is no longer taking drugs and the liver biopsy shows viral hepatitis of sufficient stage and grade, antiviral
therapy should be undertaken: interferon and either ribavirin or lamivudine for hepatitis B and C respectively. If the patient
has NASH, weight reduction should be encouraged. If the patient appears to be drinking more alcohol than was apparent
initially, then abstinence should be encouraged.

OSCE COUNSELLING CASE 8.11 – ‘Doctor, I have given up my drug habit, but have
hepatitis C. Do I need to be treated?’
Treatment for hepatitis C is determined by the stage and grade of the disease (the severity). This is determined by a liver
biopsy. Any patients who have active inflammation, but no cirrhosis, are candidates for antiviral therapy. Some patients
require no therapy, but need repeat biopsy instead.
OSCE COUNSELLING CASE 8.12 – ‘Doctor, you told me I had hepatitis A. Is there a
risk that I will pass it on?’
Hepatitis A is transmitted through poor hygiene. With good hand washing, there is no chance of passing the virus. The virus
appears only in faeces and very good hygiene will prevent its transmission.
IRRITABLE BOWEL SYNDROME

Clinical cases
CASE 8.22 – Abdominal bloating.
A 24-year-old housewife complains of abdominal bloating, which gets progressively worse during the day.
CASE 8.23 – After an elective period in India, a medical student returned to the
UK with diarrhoea.
The diarrhoea initially appeared to settle and then has gradually worsened over the 2 months before coming to see you.
CASE 8.24 – Straining to pass stool.

A 42-year-old social worker presents with a story of straining to pass stool, passage of mucus and perhaps blood on the
tissue paper.

OSCE COUNSELLING CASE 8.13 – ‘Doctor, I have severe bloating. Is it the result of
food allergy?’
OSCE COUNSELLING CASE 8.14 – ‘I have been told that I have IBS. Should I take a
fibre supplement?’
Key concepts
The aetiology of irritable bowel syndrome
The aetiology is largely unknown. Irritable bowel syndrome falls under the umbrella of ‘functional illness’. Most research
points to a role for stress – sexual abuse seems particularly important. Post-infectious IBS is well recognized following ‘food
poisoning’. Food intolerance is rarely the explanation.
How it is diagnosed?
Clinically, based on the Manning or Rome criteria. It is NOT a diagnosis of exclusion.
How is it managed?
Stressors need to be identified and managed. Counselling may be necessary. Antidepressants are sometimes helpful.
Specific drug therapy based on serotonin is not licensed at this time.
Answers
CASE 8.22 – Abdominal bloating.
A1
IBS
Bacterial overgrowth, lactose intolerance or IBD.
A2
Bacterial overgrowth, lactose intolerance and IBS can be difficult to separate from history alone. However, if the patient
reports that certain foods (milk based) exacerbated symptoms and there is diarrhoea at the same time, lactose intolerance
is a possibility. Bacterial overgrowth can mimic this.
If the patient experiences relief of abdominal pain with passing flatus or faeces, it is likely to be IBS, particularly if the
symptoms are episodic.
A3
It is important to look for duration of the illness. Irritable bowel syndrome often has insidious onset for many months
before patients seek help. Weight gain is often the case, although weight loss might be a consequence of stress. Weight
loss is, however, more likely to indicate organic disorder such as IBD or coeliac disease. Abdominal pain that is worse on the
day that the stool form is different suggests IBS. Straining to finish defecation is often found with IBS patients, as is mucus.
No blood should be present.
A4
On examination there should be no abnormal findings. In IBD, tenderness, abdominal mass or perianal abnormalities may
be found.
A5
No investigations are needed if a clinical diagnosis of IBS is made. However, normal CRP and plasma viscosity may be
reassuring.
A6
Irritable bowel syndrome is usually a consequence of stress. A careful social history should be obtained and attention paid
to counselling around the issues described by the patient. Lactose exclusion might be helpful in some patients.
CASE 8.23 – After an elective period in India, a medical student returned to the
UK with diarrhoea.
A1
Post-infectious IBS
Giardiasis.
A2
It is hard to distinguish between the differential diagnoses, but the history suggests that an infection was acquired in India,
which has led to a subtle change in the bowel habit, giving chronic diarrhoea.
A3
Weight loss might suggest that the patient has ongoing giardiasis. Most patients with IBS have episodic symptoms with
some easing from time to time. If these symptoms do not wax and wane, it is likely that the patient has giardiasis rather
than IBS.
A4
No abnormal findings are expected.
A5
Stool culture and duodenal biopsy should be undertaken to look for Giardia lamblia. A therapeutic trial of metronidazole
might be considered.
A6
If the patient has giardiasis, metronidazole will cure the problem. If Giardia lamblia is not present it is likely that the
problem is post-infectious IBS and the symptoms will gradually improve over time. Lactose avoidance may help ease the
symptoms.
CASE 8.24 – Straining to pass stool.
A1
IBS
Mucosal prolapse
Solitary rectal ulcer syndrome
Gonorrhoea
Haemorrhoids.
A2
The passage of mucus with an urge to strain suggests that the patient has rectal disease. Infrequent blood that is present
only on the tissue paper makes it unlikely that the patient has proctitis. However, this is not completely ruled out.
A3
It is important to determine whether there is an urge to strain at the start or the end of defecation. Both are often present
in IBS. If blood is present only on days when the patient strains, this suggests that the patient has haemorrhoids or solitary
rectal ulcer syndrome. Proctitis tends to give rise to frequent passage of blood in the absence of the need to strain. Sexual
practice should be tactfully investigated. Anal intercourse in either sex can cause local trauma and transmit a sexually
transmitted infection. Some patients self-digitate when they feel that have inadequately emptied the bowel. This can
traumatize the bowel.
A4
On examination nothing is expected. Sigmoidoscopy should be performed. This may show proctitis or solitary rectal ulcer in
the anterior wall of the rectum. Haemorrhoids may be seen prolapsing through the anus, however protoscopy may be
necessary to visualise them.
A5
Flexible sigmoidoscopy should be considered. Swabs should be considered if there has been anal intercourse. Physiological
studies may be necessary in patients in whom tenesmus is severe.
A6
Treatment is difficult. Stool softeners may help patients with haemorrhoids, others will require a surgical assessment with a
view to band litigation or scelerotherapy. If proctitis is present it should be treated with topical therapy (steroids or 5-ASA
compound). Any local infection should be treated with appropriate antibiotics or antiviral agents. However, most patients
will have IBS. This may respond to hypnotherapy and, in certain situations, biofeedback; this teaches patients to respond
differently to symptoms they perceive from their rectums and ‘retrains’ the manner in which they defecate.

OSCE COUNSELLING CASE 8.13 – ‘Doctor, I have severe bloating. Is it the result of
food allergy?’
It is unlikely to be caused by food allergy. However, food intolerance (especially wheat) may aggravate bloating. Milk sugar
(lactose) intolerance is a possibility – try avoiding all milk products (including goat’s and sheep’s milk) for 2 weeks and see
whether this improves your symptoms.
OSCE COUNSELLING CASE 8.14 – ‘I have been told that I have IBS. Should I take a
fibre supplement?’
No – high-fibre diets often worsen abdominal pain in IBS. Just eat a well-balanced diet and be sure to eat a mixture of fruit
and vegetables.
COELIAC DISEASE

Clinical cases
CASE 8.25 – A 44-year-old woman with anaemia.
A 44-year-old woman presents with lethargy, breathlessness on exertion and a little chest tightness on walking uphill. She
was turned down as a blood donor because of anaemia.
CASE 8.26 – A 23-year-old woman presents with impaired fertility and loose
stools.
She had loose stools throughout her teenage years. She is slightly built and has noted that it is difficult to increase her
weight.
CASE 8.27 – A patient with coeliac disease who infrequently attends clinic.
He presents with weight loss and anaemia at the insistence of his wife.

OSCE COUNSELLING CASE 8.15 – ‘I feel well. Why should I eat a gluten-free diet?’
OSCE COUNSELLING CASE 8.16 – ‘I have coeliac disease. Are my children at risk?’
Coeliac disease 261
Key concepts
The aetiology of coeliac disease
Coeliac disease is a true food allergy. An immune response to the α-gliadin component of gluten leads to an immune
infiltrate in the mucosa of the proximal small intestine, with secondary crypt hyperplasia and villous atrophy.
How it is diagnosed?
Antibodies to gliadin, endomysium and tissue transglutaminase are often found in the serum of patients with coeliac
disease. However, these antibodies lack the sensitivity and specificity to be the gold standard for making the diagnosis. The
gold standard remains the proximal small intestinal biopsy, typically obtained from the third part of the duodenum at
endoscopy.
What are the complications?
Untreated coeliac disease leads to complications associated with malabsorption – anaemia (folate and iron deficiency),
rickets and/or osteomalacia, bleeding disorders and subfertility.
Late complications include small bowel lymphoma and carcinomas arising in the small intestine, oesophagus, pharynx and
colon.
Answers
CASE 8.25 – A 44-year-old woman with anaemia.
A1
Menorrhagia
Dietary insufficiency (vegetarian)
Coeliac disease.
A2
The history is consistent with progressive iron-deficiency anaemia; lack of overt blood loss in the presenting complaint
suggests malabsorption or menorrhagia as likely causes.
A3
Dietary history should be obtained to exclude vegetarianism. Gynaecological history should be pursued to look for
menorrhagia. A subtle change in the bowel habit should be sought that might suggest coeliac disease.
A4
Nothing is expected on examination except evidence of anaemia, perhaps with cheilosis or mouth ulcers.
A5
Duodenal biopsy; some clinicians use anti-endomyseal antibodies as a justification for duodenal biopsy. If the dietary
history is non-contributory and the gynaecological history unremarkable, coeliac disease is the most likely explanation.
However, further investigations may be called for if coeliac disease is not found.
Coeliac disease 263
A6
Treatment of coeliac disease is a gluten-free diet with possible mineral and vitamin supplements. The patient should be
encouraged to join the Coeliac Society.
CASE 8.26 – A 23-year-old woman presents with impaired fertility and loose
stools.
A1
Coeliac disease
Crohn’s disease
Hormone disturbance, e.g. thyrotoxicosis
Anorexia nervosa.
A2
The clue is the loose stool; without this the differential diagnosis would be quite broad. Anorexic patients rarely complain
of inability to gain weight, so this is unlikely. Crohn’s disease, thyrotoxicosis and coeliac disease are all genuine differential
diagnoses of diarrhoea and subfertility.
A3
The nature of the stool should be investigated; pale, bulky, floating stools would suggest steatorrhoea; bloody diarrhoea
would suggest Crohn’s disease. Features of thyrotoxicosis (tremors and sweats) should be sought to rule out thyroid
disease. Abdominal pain is unlikely in coeliac disease, but common in Crohn’s disease.
A4
On examination, little is expected in patients with coeliac disease. However, clubbing and anaemia may be present. Mouth
ulcers are also relatively common. A goitre would point to thyroid dysfunction and proptosis would suggest Graves’
disease.
A5
Anti-endomyseal antibodies and/or duodenal biopsy should be obtained. Duodenal biopsies are standard investigation.
Thyroid function should be assessed if the duodenal biopsy is normal. Consideration should be given to a barium follow-
through.
A6
The treatment for coeliac disease is a gluten-free diet.
The treatment for thyrotoxicosis is carbimazole and/or radiotherapy with thyroxine replacement.
Crohn’s disease is treated according to symptoms; a 5-ASA compound may be used as maintenance medication.
CASE 8.27 – A patient with coeliac disease who infrequently attends clinic.
A1
Poor compliance with relapse of coeliac disease. Lymphoma or small bowel carcinoma complicating poorly controlled
coeliac disease.
A2
Poor clinic attendance suggests non-compliance. History from his wife would be useful to support this.
A3
Diet should be reviewed, and barium follow-through and duodenal biopsy considered.
Coeliac disease 265
A4
Lymphadenopathy may be present, but often lymphoma in the GI tract does not present with lymphadenopathy.
A5
Duodenal biopsy, barium follow-through and CT scan of the abdomen.
A6
Re-introduction of gluten-free diet for coeliac disease
Oncological assessment with radiotherapy and/or chemotherapy (? if lymphoma.)


OSCE COUNSELLING CASE 8.15 – ‘I feel well. Why should I eat a gluten-free diet?’
Most patients with coeliac disease have insidious symptoms gradually leading to presentation with diarrhoea and/or
anaemia. Without control of coeliac disease, malabsorption as a consequence will occur in most patients. Untreated coeliac
disease increases the risk of lymphoma and gastrointestinal malignancy.
OSCE COUNSELLING CASE 8.16 – ‘I have coeliac disease. Are my children at risk?’
There is a weak association. This is not simple inheritance such as might be found in patients with haemophilia or cystic
fibrosis. Although the risk to your children is small, a delay in weaning or prolonged breast-feeding is thought to be helpful.
If the child fails to thrive coeliac disease should be considered.
9General surgery
Matthew Clark and Steven Thrush
268 General surgery
Key concepts
Landmarks for postoperative care and complications
First 24 hours
Primary haemorrhage is the most common feature presenting as a tachycardia. Initially a fit young patient will have a
stable blood pressure (BP) because the haemodynamic system is able to compensate. This is followed by hypotension
because the circulatory system is no longer able to compensate. Resuscitation with colloids is essential, well before
decompensation occurs.
A raised temperature (< 37.9°C) in the first 24-hour period is usually a postoperative reactive pyrexia but a rise > 38°C is
suspicious of a urinary tract infection (UTI) that was pre-existing but flared up after urinary catheterization.
24–72 hours
Infection of the urinary tract, chest, surgical wound and legs must be checked for causes for pyrexia during this time period.
After abdominal surgery, a pyrexia in this time period should also raise suspicion of direct injury to the bowel that was
missed during surgery and has caused peritonitis.
7–10 days
Secondary haemorrhage caused by infection
Thrombrosis (deep venous or pulmonary embolus)
Fistula formation from avascular necrosis (diathermy burns) presenting as late complication, e.g. ureteric fistula,
vesicovaginal fistula, rectovaginal fistula or bowel perforation causing peritonitis.
The four Bs
Decision aid for emergencies needing surgical intervention as out-of-hours procedure – remembered as the four ‘B’s:
Block, e.g. subacute obstruction
Bleed, e.g. peptic ulceration
Burst, e.g. ectopic pregnancy
Break, e.g. bones requiring repair.

Hernias 269
HERNIAS

Clinical cases
CASE 9.1 – ‘I’ve developed a new lump in my groin.’
A 25-year-old army sergeant suddenly develops a golfball-sized, slightly tender lump in his right groin after lifting some
heavy equipment, and states that he felt a ‘tearing’ sensation as it happened. He is referred by the army medics to the
accident and emergency department (A&E).
CASE 9.2 – ‘I can’t push the lump away anymore.’

A 67-year-old retired builder presents to the outpatient clinic with a slightly tender lump in his left groin. In the past it has
often disappeared overnight and was more noticeable after exertion – he had been able to ‘push’ the lump back inside. His
health is otherwise fine, but he does cough as a result of years of smoking. Over the last 2 weeks, he has no longer been
able to reduce the lump.
CASE 9.3 – ‘My hernia is sore, and I’ve started to vomit.’

A slim 73-year-old woman has had a groin lump for some time, which she ignored. Over the last 3 days it has become
progressively more painful, with redness of the overlying skin. She has not passed a bowel motion during this time
(unusual for her), and yesterday she started to vomit.

OSCE COUNSELLING CASE 9.1 – ‘Should I have my hernia repaired?’
A 47-year-old man presents, via his GP, with an intermittent left groin mass, causing only moderate symptoms. Examination
confirms an inguinal hernia that can easily be reduced.
Q1: If an operation is offered, what specific risks should the patient be warned about?
270 General surgery
OSCE COUNSELLING CASE 9.2 – ‘Why did my surgeon suggest I have my prostate
‘re-bored’ first?’
An otherwise well 73-year-old man has a right inguinal hernia and elects to proceed with hernia repair. On history,
however, he admits to slight difficulty initiating urination, poor urinary stream and nocturia (he gets up three times each
night on average). The surgeon suggests a visit to a urologist before proceeding with the operation.
Q1: What factors might the surgeon be thinking about in deferring the operation?
Q2: What will the urologist do?
Key concepts
What is a hernia?
‘A protrusion of a viscus beyond its proper cavity is denominated a hernia.’

Sir Astley Cooper
Where do they occur?
Hernias may occur anywhere in the body. Groin hernias are the most common, usually occurring through the complex
anatomy of the inguinal canal. Other sites for hernias include where musculofascial weaknesses may develop (diaphragm,
lumbar triangle, edge of rectus abdominis), where abnormal stresses are found (cerebral tumours causing ‘coning’) or as a
complication of wound healing (‘incisional hernia’).
What can they contain?
Just about anything. Omentum and the mobile small bowel are the usual suspects, but most organs (including the
pregnant uterus) have been described in hernias at various points. Sometimes the organs may have pathology, such as
Meckel’s diverticulum (the rare Littre’s hernia).
Why are they important?
As well as discomfort from the hernia itself, the main importance is the risk of complications. Scarring may lead to
irreducibility of contents (incarceration) and possibly obstruction of any contained bowel. If the blood supply of the
contents is compromised, this may cause ischaemia (strangulation), necrosis and even perforation.
Hernias 271
Answers
CASE 9.1 – ‘I’ve developed a new lump in my groin.’
A1
Inguinal hernia
Femoral hernia
Enlarged lymph node
Rare: saphena varix (dilatation of saphenofemoral junction); aneurysm; tumour.
A2
Groin hernias may be caused by heavy exertion, but often no precipitating event is determined and the onset is slower.
Tenderness is common, particularly in an acute-onset hernia, but may also be a feature of an inflamed lymph node. The
young age of the patient makes the rarer conditions less likely.
A3
Ask whether the patient has had hernias before (making future hernias more likely) and about a family history of hernias.
A4
Examine the groin and external genitalia. The diagnostic characteristic of a hernia is a cough impulse, in a mass passing
through the inguinal canal (indirect inguinal hernia), sometimes right down into the scrotum, or sometimes directly through
the medial posterior wall of the inguinal canal (direct inguinal hernia). Although technically possible to distinguish between
indirect and direct hernias, it makes no difference to treatment.
272 General surgery
A5
Ultrasonography may be useful to differentiate between clinically unclear entities.
Fine-needle aspiration biopsy (FNAC) of enlarged lymph node(s) if detected.
A6
Supportive: hernia trusses have been used in the past, but play no useful role.
Medical: no role.
Surgical: hernia repair (herniorraphy, hernioplasty) is recommended for most patients with a groin hernia, in order to
minimize the risks of future complications. The most common option for repair is an open approach through the groin
(usually using a permanently implanted plastic mesh), although a laparoscopic approach is possible and may be useful
for recurrent hernias, bilateral hernias and in high-performance athletes.
Ideally, the patient should stay in hospital and have his hernia repaired on the next available operating list. Realistically, he
will probably be sent home for an early operation date.
CASE 9.2 – ‘I can’t push the lump away anymore.’
A1
Inguinal hernia
Femoral hernia, now irreducible
Enlarged lymph node (infection, metastatic tumour)
Femoral artery aneurysm; saphena varix.
A2
A groin mass that has been irreducible in the past, and is no longer so, is a very clear history diagnostically. The older age
of the patient also increases the likelihood.
Hernias 273
A3
Ask about urinary symptoms – benign prostatic hypertropy (BPH) is not uncommon in this age group and may lead to
postoperative urinary retention.
A4
Examine the groin and external genitalia. Carefully check the other groin for hernias; patients sometimes have a subclinical
hernia on the contralateral side. Perform a digital rectal examination (DRE) to exclude prostatic enlargement.
A5
Ultrasonography may be useful to differentiate between clinically unclear entities.
A6
Supportive: no role.
Medical: no role.
Surgical: early elective hernia repair is indicated.
CASE 9.3 – ‘My hernia is sore, and I’ve started to vomit.’
A1
Inguinal hernia, now with ischaemia and bowel obstruction
Femoral hernia, with ischaemia and bowel obstruction
Infected lymph node.

274 General surgery
A2
The change in the groin lump in addition to pain, vomiting and constipation would suggest small bowel obstruction
secondary to an obstructed hernia.
A3
Exclude infections that may drain to the inguinal lymph nodes. Local inflammation may explain the redness and tenderness
and, if the patient is systemically unwell, this may secondarily cause paralytic ileus with vomiting.
A4
Examine the groin carefully. Femoral hernia is seen more often in women than in men, although inguinal hernia is still more
common. (If present, femoral hernia is more likely to cause ischaemia as a result of the tight neck of the femoral canal.)
Femoral hernia will be found below the inguinal ligament and medial to the femoral arterial pulse.
A5
A plain abdominal radiograph will confirm the clinical suspicion of bowel obstruction. Other investigations are directed at
preparing the patient for the operating theatre.
A6
Medical: bowel obstruction is associated with significant fluid and electrolyte abnormalities – the patient should be
aggressively resuscitated with the expectation of going to theatre within a few hours. Nasogastric tube drainage will
make the patient more comfortable, minimizing vomiting and the risk of aspiration.
Surgical: emergency surgery is needed. This usually consists of a laparotomy (via the lower midline, although other
options are available) and possibly resection of any dead bowel. Usually the ends are re-anastomosed. The hernia itself
is repaired at the same time, either through the usual groin incision, or from inside the abdomen.
Hernias 275

OSCE COUNSELLING CASE 9.1 – ‘Should I have my hernia repaired?’
A1
Risks may be a result of the condition itself or the treatment of the condition.
Risks of the treatment may be anaesthetic or operative.
Operative risks may be those that are general to any operation or specific to this procedure.
General risks of any operation include bleeding from operative sites (minimized by careful surgery, stopping aspirin and
anticoagulants if safe), wound infection (consider prophylactic antibiotics, reducing cross-contamination from other
patients), early pain or discomfort.
Operative risks specific to this procedure may be early or late.
Specific risks to consider in groin hernia repair are recurrence of hernia (i.e. failure of treatment), scrotal haematoma,
impairment of vascular supply to testicle (ischaemic orchitis) or late neuralgic pain from wound.
Patients usually need to make a choice about whether to proceed with an operation based on their assessment of the risks
of the procedure versus the risks of the underlying condition. The best source of this information is the medical team, based
on published evidence (where present) or best opinions. There is a strong consensus that groin hernia should usually be
repaired surgically when present.
OSCE COUNSELLING CASE 9.2 – ‘Why did my surgeon suggest I have my prostate
‘re-bored’ first?’
A1
Benign prostatic hypertrophy is a relatively common condition in elderly men. Rarely, similar symptoms are caused by
carcinoma of the prostate. Most patients cope well with their symptoms, which are usually gradual in onset. Occasionally,
hernia operations may trigger acute urinary retention as a result of a combination of anaesthetic drugs, the fluid load given
perioperatively and discomfort from the wound. This might require treatment with an indwelling urinary catheter; it could
result in a prolonged hospital stay and perhaps leaving the catheter in place until urological assessment.
A2
A urologist will take a thorough history, perform a complete physical examination including digital rectal assessment of the
prostate and arrange further investigations. The last may include blood tests for prostate-specific antigen (PSA), transrectal
ultrasonography (TRUS) of the prostate, possibly with transrectal biopsy of the prostate, or cystoscopy to assess the bladder
and prostatic urethra. Medications may be all that is required to minimize symptoms. Transurethral resection of the prostate
(TURP) via a cystoscope may be appropriate to decrease the resistance to urinary flow; all else being equal, this is best
performed before other surgery such as hernia repair.
276 General surgery
GALLSTONES

Clinical cases
CASE 9.4 – ‘My GP tells me my pain is caused by gallstones.’
Right upper quadrant pain after fatty meals prompts a 26-year-old woman to see her GP. The pain is felt under the ribs and
in her back, and comes on over a 1-hour period, lasting up to 4 hours. It is quite severe. She is nauseated, but never vomits.
The GP refers her for a surgical opinion, but suggests that the pain will probably turn out to be gallstones.
CASE 9.5 – ‘The worst ever! It’s not going away, and I’ve got a fever.’
A 31-year-old woman has had typical biliary pain for many months, but has been reluctant to consider an operation. She
now has an episode of pain that has lasted 18 hours without let-up, which she says is ‘the worst ever!’. She feels flushed
and has a temperature of 37.9°C. Nausea and, more recently, vomiting are a feature.
CASE 9.6 – ‘My eyes are going yellow, and my skin is itching.’
This 61-year-man has had niggling epigastric pain for some months. Over the last week his wife has commented that his
eyes are yellow tinged; he has noticed that he is getting very itchy skin.

OSCE COUNSELLING CASE 9.3 – ‘But I don’t have pain – do I need an operation?’
During an antenatal scan, a 26-year-old woman is noted to have small mobile gallstones. When questioned, she has no
pain that is typical of biliary colic. She is referred by her obstetrician for a surgical opinion as to whether she should
undergo cholecystectomy.
Q1: Should she be offered an operation?

Gallstones 277
OSCE COUNSELLING CASE 9.4 – ‘What is this ERCP thing that you think I should
have?’
Six weeks after delivery, the same young woman develops epigastric pain and jaundice; ultrasonography reconfirms the
gallstones and shows dilatation of the common bile duct to 11 mm. Endoscopic retrograde cholangiopancreatography is
recommended.
Key concepts
How do gallstones form?
Bile consists of water, electrolytes, cholesterol, bile salts and lecithin (among other things). In the usual situation these are
all in solution. In some patients the bile becomes ‘lithogenic’ (stone forming) and the constituents precipitate out around a
nucleus of cellular debris or bacteria. Gallstones are formed.
What clinical problems might they cause?
Consider the problems by site:
Gallbladder: asymptomatic, biliary pain (colic), inflammation (cholecystitis), perforation, gallbladder carcinoma
Bile ducts: asymptomatic, obstructive jaundice, ascending cholangitis, gallstone pancreatitis
Unusual: cholecystoenteric fistula with gallstone ileus.
What imaging options are used for gallstones and the biliary tract?
Ultrasonography is usually the investigation of choice for suspected gallstones. Plain films may show the 10 per cent of
gallstones that contain calcium; HIDA scan is now mainly of historic interest. Endoscopic retrograde
cholangiopancreatography gives excellent images of the lumen of the bile ducts, and allows therapeutic options such as
sphincterotomy and stone extraction. Magnetic resonance cholangiopancreatography (MRCP) equals the image quality of
ERCP but without the risks.
278 General surgery
Answers
CASE 9.4 – ‘My GP tells me my pain is caused by gallstones.’
A1
Biliary colic
Peptic ulcer disease.
A2
Pain associated with gallstones commonly occurs after fatty meals, as the cholecystokin released causes the gallbladder to
contract onto the stones. As a result of the hormonal nature of the stimulus, the onset is slow but the duration somewhat
prolonged. Nausea is common. Back (or sometimes right shoulder) discomfort is probably the result of referred pain
pathways.
A3
Sometimes a family history is present, but may be a result of learned eating patterns rather than a genetic tendency to form
gallstones. Check for symptoms of upper gastrointestinal (GI) bleeding or gastro-oesophageal reflux – such diseases may
coexist with gallstones, making determination of whether the gallstones are truly symptomatic a challenge.
A4
Abdominal examination should be done, but frequently no signs are found. Check for signs of jaundice. Are there any
abdominal scars? This may make a laparoscopic approach to the gallbladder more difficult.
A5
Blood tests, specifically looking for evidence of ductal calculi (i.e. elevated bilirubin, amylase).
Imaging: ultrasonography will usually show the presence of gallstones and verify that the common bile is not dilated.
Gallstones 279
A6
Supportive: dietary modification may be tried in those who are reluctant to consider surgery. Cutting out fatty meals
may reduce feelings of nausea or decrease frequency of painful episodes.
Medical: although medical options to dissolve gallstones have been tried in the past, these are generally unsuccessful.
Surgical: most patients with symptomatic gallstones should have the gallbladder removed (cholecystectomy).
Laparoscopic cholecystectomy can be performed in around 95 per cent of patients; the remaining 5 per cent have an
intraoperative conversion to an open technique or a preoperative decision to start the operation open. In some
countries where laparoscopic resources are unavailable, ‘mini-cholecystectomy’ may result in a 5 cm scar, comparable
to the total incision length of the laparoscopic approach.
CASE 9.5 – ‘The worst ever! It’s not going away, and I’ve got a fever.’
A1
Acute cholecystitis
Ascending cholangitis
Right lower lobe pneumonia.
A2
The constant nature of the pain, together with systemic unwellness, suggests supervening infection of the gallbladder.
A3
Exclude symptoms of other infections – cough, urinary frequency. If jaundice is present, ascending cholangitis (blockage by
stone in common bile duct, infection ascending into liver) should be considered.
280 General surgery
A4
There may be tenderness or even peritonism in the right upper quadrant. Seek Murphy’s sign – the cessation of inspiration
as an inflamed gallbladder descends onto the examining fingers in the right upper quadrant. Charcot’s triad (jaundice,
fever, bed-shaking rigors) indicates a late stage of cholangitis.
A5
Blood tests will usually show an elevated white cell count (WCC) (> 15 × 109/L). Electrolytes should be normal unless
dehydration from vomiting is present. Liver function tests (LFTs) may be mildly deranged, but high bilirubin or amylase
suggests complications.
Ultrasonography will confirm stones (if not already known), and may show typical features of acute cholecystitis – wall
thickening, pericholecystic fluid, the so-called ‘sonographic’ Murphy’s sign. If perforation or abscess has occurred, these
should be evident. In a severely ill patient, CT may be more appropriate.
A6
Supportive: fluid resuscitation and analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs).
Medical: antibiotics have traditionally been used to resolve acute cholecystitis; not all have good bile penetration so
choose carefully according to local sensitivities. Often a prolonged course (10–14 days) is required. A minority fail to
settle and will need operative management. Some surgeons advocate early laparoscopic cholecystectomy, claiming
that it is safe and cost-effective. The alternative is a further admission in 6 weeks for elective cholecystectomy.
Other: in a patient who is at high risk of complications, percutaneous image-guided drainage of an empyema (pus-
filled gallbladder) may be considered, usually together with antibiotics.
CASE 9.6 – ‘My eyes are going yellow, and my skin is itching.’
A1
Obstructive jaundice from gallstones
Obstructive jaundice form malignancy (e.g. pancreatic carcinoma)
Other cause of jaundice.

Gallstones 281
A2
Pain from gallstones in the ductal system is often intermittent and difficult to characterize. Obstructive jaundice classically
results in skin and scleral colour changes, and intense itch, with darker urine – all caused by bilirubin. Weight loss is a
danger sign of malignancy, often indicating advanced disease.
A3
Exclude other causes of jaundice: pre-hepatic and hepatic (compare post-hepatic or obstructive)
Any new medications?
Blood transfusions?
Sickle-cell disease?
A4
Carefully examine the abdomen, particularly for masses. Check the supraclavicular fossa on the left. Look for systemic signs
of liver disease, starting at the hands and working centrally.
A5
Blood tests should check the LFTs, including clotting parameters (which are a good overall test of hepatic synthetic
function).
Imaging should start with ultrasonography, which is best for detecting the presence of gallstones. Computed tomography
(CT) or magnetic resonance imaging (MRI) is superb at defining the site and characteristics of a mass, if present. ERCP and
MRCP will both image the bile ducts well, but ERCP has therapeutic potential as well.
A6
Supportive: good hydration is important, because those with jaundice are more prone to renal impairment.
Medical: bile-penetrating antibiotics are often started to minimize the risk of ascending infection.
282 General surgery
Other: ERCP with endoscopic clearance of stones is usually carried out before definitive treatment. This is not totally
without risk: a small number can get pancreatitis, bleeding or perforation, or die from the procedure.
Definitive treatment involves removing the gallstone-producing factory, the gallbladder. The bile ducts can be explored
intraoperatively by radiological means using an image intensifier (cholangiography) or with flexible fibreoptic instruments
(choledochoscopy).
Gallstones 283

OSCE COUNSELLING CASE 9.3 – ‘But I don’t have pain – do I need an operation?’
A1
Gallstones are common, and becoming more so with ‘westernized’ diets. Only about 30 per cent of those with gallstones
eventually come to surgery, and generally symptoms become gradually (rather than rapidly) worse; about 2 per cent with
asymptomatic gallstones develop biliary colic each year.
Some groups should have cholecystectomy considered even for asymptomatic gallstones, including those with diabetes
(who have high rates of complications if cholecystitis occurs) and those with a calcified gallbladder on radiograph
(associated with gallbladder cancer).
OSCE COUNSELLING CASE 9.4 – ‘What is this ERCP thing you think I should have?’
Endoscopic retrograde cholangiopancreatography is a diagnostic and therapeutic procedure, usually performed by
gastroenterologists or GI surgeons. A special side-viewing endoscope (duodenoscope) has channels through the instrument
to allow cannulae and instruments to be guided into the biliary tree under direct vision or video monitoring. Radio-opaque
dye can delineate the anatomy of the bile ducts, and identify common bile duct stones or strictures such as cancer.
Electrocautery can enlarge the sphincter of Oddi (‘sphincterotomy’) and special baskets and crushing forceps can clear the
duct of stones. Tumours can be biopsied by special forceps, or brushings of the duct for cytology can be obtained.
This procedure is a highly specialized area requiring dedicated equipment, and even with experts has a small failure rate.
Complications are rare, but include bleeding or perforation (from sphincterotomy), pancreatitis (probably from high-
pressure dye injection) and death in around 0.5 per cent.
284 General surgery
APPENDICITIS

Clinical cases
CASE 9.7 – ‘I’ve got a really bad pain in my right side.’
A 17-year-old man comes into A&E with a 12-hour history of nausea, lack of appetite and vague pain that is now
becoming more severe and localized to the right side.
CASE 9.8 – ‘I’ve developed another episode of pain on the right.’

Moderate right-sided lower abdominal pain has brought a 24-year-old woman to the surgical assessment unit. She has had
this on two previous occasions, with no diagnosis being made. The pain is constant, and makes her nauseated.
CASE 9.9 – ‘The pain is getting worse, and I’ve started to vomit.’
This 45-year-old businessman has delayed coming into hospital (‘can’t stand the place’) and is now doubled over with
severe pain, vomiting and rigors. When seen, he is tachycardic and has a palpable abdominal mass in the right iliac fossa.

OSCE COUNSELLING CASE 9.5 – ‘I’m going to overwinter in the Antarctic. Should I
have my appendix removed beforehand?’
A 32-year-old male meteorologist is planning to spend 6 months at a research station in the Antarctic; this sometimes
becomes inaccessible to medical evacuation flights for up to a month at a time. He has heard that sometimes prophylactic
appendicectomy is performed in this situation.
Q1: What would you advise?

Appendicitis 285
OSCE COUNSELLING CASE 9.6 – ‘Why has my wife developed complications after
her appendicectomy?’
After having her appendix removed last week, a 44-year-old woman has started to feel progressively more unwell, with
lower abdominal pain and fevers and diarrhoea. Her GP sends her back into hospital, where a pelvic abscess is diagnosed
on abdominal CT.
Q1: What will you tell this woman about why this has happened?
Key concepts
What is appendicitis?
Inflammation of the appendix is usually caused by obstruction of the lumen by a faecolith (a small hard ball of faecal
material), with subsequent stasis, bacterial growth, impairment of the blood supply, necrosis of the wall and finally
perforation if not treated promptly.
What happens if the appendix perforates?
The omentum has been described as the ‘policeman of the gut’, and tends to wall off serosal inflammation of the
appendix. Perforation may be contained by the omentum (or other surrounding structures) to form a localized abscess. If
this does not happen, generalized peritonitis is likely.
286 General surgery
Answers
CASE 9.7 – ‘I’ve got a really bad pain in my right side.’
A1
Acute appendicitis
Gastroenteritis
Mesenteric adenitis
Crohn’s disease of the terminal ileum.
A2
Appendicitis is typically preceded by a vague abdominal pain, because visceral inflammation is often poorly localized to the
midline; organs derived from the midgut (like the appendix) usually have pain referred to the periumbilical region. As
continued inflammation spreads to the serosal surface, and involves the body wall, the pain tends to localize to where the
appendix is located. Nausea and anorexia go hand in hand with GI inflammation.
A3
Has the patient had this type of pain previously? Recurrent pains are atypical of appendicitis (‘grumbling’ appendicitis,
while beloved of GPs, probably does not exist). Check about other GI symptoms, particularly diarrhoea; in appendicitis,
these usually follow the initial pain or discomfort.
A4
Abdominal examination should seek to differentiate tenderness (mild-to-moderate pain on palpation) from guarding
(increased muscular tone) or peritonism (guarding with moderate-to-severe pain). Cough and percussion tenderness are
hallmarks of peritonism, and with the appropriate history are often diagnostic of acute appendicitis. Rebound tenderness is
unreliable and cruel, and should never be performed.
Digital rectal examination has been considered mandatory in suspected appendicitis in the past, but realistically adds little
in most patients without a specific indication.
Repeated clinical examination is useful in borderline cases. A 12-hour period of observation with repeated examination is
almost always safe, and better than operating in the middle of the night.
Appendicitis 287
A5
WCC and inflammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) are usually moderately
raised in appendicitis. Other blood tests are normal.
UTI can be excluded by midstream urine (MSU).
Plain abdominal radiographs add little diagnostically. Limited CT of the right iliac fossa is highly sensitive and specific
for appendicitis, but is usually not available.
A6
Medical: it is probable that broad-spectrum antibiotics alter the course of early appendicitis but, once serosal
inflammation or ischaemia/necrosis of the wall has occurred, the appendix will progress to perforation unless removed.
Antibiotics (one regimen is cefuroxime plus metronidazole) may be used prophylactically at operation to reduce wound
infection, or as postoperative treatment if perforation has occurred.
Surgical: appendicectomy is indicated. This is usually performed with an open incision in the right iliac fossa, although
laparoscopic techniques are also used (particularly following a diagnostic laparoscopy; see next section).
CASE 9.8 – ‘I’ve developed another episode of pain on the right.’
A1
Non-specific abdominal pain
Appendicitis
Right-sided gynaecological pathology (ovarian cyst, pelvic inflammatory disease, ectopic pregnancy)
Crohn’s disease, gastroenteritis, biliary colic or cholecystitis (if gallbladder low).
A2
The previous episodes of pain suggest a recurring problem, although it is not unheard of to have similar episodes before
frank acute appendicitis.
288 General surgery
A3
Could she be pregnant? A careful gynaecological and sexual history is mandatory in this situation. Urinary symptoms
should also be elicited.
A4
As well as abdominal examination, vaginal and pelvic examination should be performed. Masses, tenderness, vaginal
discharge and cervical excitation should all be sought.
A5
Pregnancy test before almost anything else.
Basic blood tests including WCC, haemoglobin (Hb), urea and electrolytes (U&Es).
MSU to exclude UTI.
Traditionally, ultrasonography (transvaginal being better than transabdominal) has been used for assessment of right
iliac fossa pain in women. However, this frequently fails to lead to a diagnosis.
Diagnostic laparoscopy is being used more aggressively in many units, e.g. if pain is not settling after overnight
observation. It has the benefit of directly visualizing the pelvic organs and appendix, and the ability to proceed to a
therapeutic procedure if appropriate.
A6
Supportive: fluids, analgesia and a period of 12 hours of observation are useful when the diagnosis is equivocal. Those
with mild pain that resolves may then drink, eat, mobilize and be discharged without follow-up.
Medical: no role, although antibiotics may be used when surgical delay is inevitable, e.g. in some rural communities.
Surgical: operation is indicated for definite or deteriorating signs and symptoms. It is generally considered that a
‘negative appendicectomy’ (i.e. operating on and removing an uninflamed appendix) is a less dangerous option than
prevaricating and allowing perforation, abscess or peritonitis.
Appendicitis 289
CASE 9.9 – ‘The pain is getting worse, and I’ve started to vomit.’
A1
Appendix mass
Appendix abscess
Perforated Crohn’s disease or perforated caecal cancer.
A2
This story is typical of ‘missed’ appendicitis; patients usually present within 24–48 hours of symptoms starting. If the
appendix perforates, systemic signs of inflammation are often more severe.
A3
Gastrointestinal symptoms that have been present for a long period may point to underlying pathology such as
inflammatory bowel disease (Crohn’s disease). Neoplasms may be silent in the caecum as a result of liquid stool and large
calibre of the bowel, but may result in iron-deficiency anaemia with consequent lethargy.
A4
Abdominal examination has found a mass; confirm that it is tender, without hurting the patient. If it contains gas, it may be
resonant to percussion.
A5
Basic blood tests may show a markedly elevated WCC (only mildly raised in uncomplicated appendicitis). Anaemia may hint
at a caecal neoplasm. Liver function tests (aspartate aminotransferase [AST]/alanine aminotransferase [ALT]) may be
deranged if the patient is septic.
Plain abdominal films may show an ileus or frank bowel obstruction, and occasionally free gas is seen under the diaphragm
on chest radiograph. Ultrasonography or CT of the abdomen is urgently indicated (i.e. same day), because it will determine
emergency management.
290 General surgery
A6
Supportive: fluid resuscitation and analgesia are needed.
Medical: if an appendix mass (without abscess) is found, broad-spectrum antibiotics targeted against gut organisms
should be given; ciprofloxacin and metronidazole is one suggested combination, usually given for 5 days. If the patient
settles with this treatment, only 20 per cent develop ‘recurrent’ appendicitis. If an interval appendicectomy is not
performed, any underlying bowel disease should be excluded with a colonoscopy or barium enema in those aged over
40 years old.
Radiological: if a localized appendix abscess is present, percutaneous drainage with ultrasound or CT guidance may
avoid an initial operation.
Surgery will be needed if the inflammation is localized (appendicectomy via the usual incision or midline laparotomy) or if
generalized peritonitis is present (laparotomy to allow washout of the abdomen, with appendicectomy). Perforated Crohn’s
disease or cancer may require resection of a bowel segment – rejoining of the bowel may be unwise in the presence of
severe infection, so a stoma may need to be brought to the body surface temporarily.
Appendicitis 291

OSCE COUNSELLING CASE 9.5 – ‘I’m going to overwinter in the Antarctic. Should I
have my appendix removed beforehand?’
A1
Appendicitis occurs in about 6 per cent of people over their lives, most often in the second or third decade. The risk in any
6-month period for an individual is quite small, and impossible to predict. One might naturally be concerned about such a
possibility if access to medical care might be difficult. The risk of complications for an (potentially unnecessary) operation
needs to be balanced against the risk of the illness itself very carefully.
Laparoscopic appendicectomy has probably reduced the morbidity of such procedures even further, and many surgeons
would at least consider such a request in the appropriate circumstances.
OSCE COUNSELLING CASE 9.6 – ‘Why has my wife developed complications after
her appendicectomy?’
Medical interventions (and many investigative procedures) have the potential to cause harm as well as good. Informed
consent should include information about common adverse events, as well as rare complications that may have a
significant impact. Patients should always have ample opportunity to ask as much about their care as they feel appropriate.
This is sometimes harder to do in the emergency situation.
Pelvic abscess is an uncommon but recognized complication of appendicitis. Appropriate medical care, including drainage
and antibiotics, should minimize the risk of long-term sequelae.
292 General surgery
COLON AND RECTAL CANCER

Clinical cases
CASE 9.10 – ‘I’ve developed rectal bleeding.’
A 45-year-old woman has intermittently noticed some dark liquid blood and occasional blood clots in her bowel motions
over the last 3 months. She is well otherwise and her bowel habit has not altered.
CASE 9.11 – ‘My bowel habit has changed.’

The 48-year-old husband of the same woman mentions that he is troubled by not passing a motion as frequently as usual,
and when he does sometimes it seems looser. He once noticed some bright red blood on the toilet paper. He is worried
because his older brother developed bowel cancer when he was in his late 40s.
CASE 9.12 – ‘It feels like I can’t finish my bowel motion.’

A 74-year-old man has been complaining of intermittent colicky abdominal pains, with frequent dark blood in the stools.
Over the last 2 months he has noticed that he feels ‘funny’ deep inside his pelvis when he passes a motion, and never feels
like he has emptied properly. His trousers seem looser and he has had to punch another hole in his belt.

OSCE COUNSELLING CASE 9.7 – ‘What do I need to know about colonoscopy?’
The 45-year-old woman in Case 9.10 had a colonoscopy organized, and was anxious about the procedure. She understood
the need for the test, but heard that it was very painful.
Q1: What are the risks of colonoscopy?

OSCE COUNSELLING CASE 9.8 – ‘Why are they talking about radiotherapy before
my bowel cancer operation?’
A 66-year-old man with rectal bleeding and tenesmus is found to have a large, fixed mass on rectal examination. Biopsies
confirm rectal cancer and MRI shows probable metastatic nodes in the mesorectum. A referral for preoperative
radiotherapy is made.
Q1: What does radiotherapy add?
Q2: Are there any side effects that the patient needs to know about?
Key concepts
What is the difference between colon and rectal cancer?
Although these are technically the same disease – epithelial neoplasia of the lining of the large bowel – they present with
a different spectrum of disease as a result of characteristics of the site. In the right colon, huge growth can occur with little
in the way of symptoms, and anaemia is common. In the left colon, dark but noticeable bleeding may be the most common
symptom. Rectal cancers occurring near the anus in the confined pelvis may have brighter bleeding or defecation symptoms
(e.g. tenesmus, a feeling of incomplete evacuation).
Surgery and other treatments may differ markedly by site; radiotherapy is often used in the pelvis for rectal cancer, whereas
chemotherapy may be used for advanced colon cancer.
What causes colon cancer?
There is now a well-defined pathway from normal colonic epithelium, to dysplastic changes in the cells, to early neoplasia
(such as benign polyps) and subsequently to true malignancy – this is the so-called adenoma–carcinoma sequence. This
pathway suggests that finding and treating benign polyps early may reduce the risk of later cancer. How might we do this?
What are the principles of treatment of colorectal cancer?
The aim of treatment should obviously be curative, but, where this is not possible, local control of disease is important.
Obstruction and bleeding are the most important local complications of colorectal cancer and resection of the affected
bowel (even in the presence of metastases) is usually appropriate. Chemotherapy and radiotherapy are important treatment
modalities in specific situations; multidisciplinary assessment should be the rule rather than the exception.
294 General surgery
Answers
CASE 9.10 – ‘I’ve developed rectal bleeding.’
A1
Haemorrhoids
Proctitis/colitis
Bleeding from polyp or cancer.
A2
With a non-specific history of bleeding that is not ‘typically’ haemorrhoidal (e.g. bright red, painless, only associated with
defecation) in a patient aged over 40 years, other sources for the bleeding need to be considered and excluded. The lack of
other symptoms makes serious pathology less likely, but remember that early cancer may have minimal symptoms.
A3
Check for an alteration of bowel habit. Is there a family history of bowel cancer? If sinister causes for the bleeding are
ultimately excluded, a careful dietary history may reveal too little fibre in the diet – this is a common theme in minor
anorectal conditions.
A4
The critical examination is of the abdomen including a DRE. The subtleties of abdominal examination are not needed, but
masses should be sought and identified. Initially proctoscopy and sigmoidoscopy may be omitted if equipment is
suboptimal, but it is indefensible not to perform a rectal examination when rectal bleeding is the presenting complaint.
A5
If the index of suspicion for malignancy is low, rigid sigmoidoscopic examination (which actually best examines the rectum,
not the sigmoid – in the USA, this is called a proctoscope [procto = rectum] and the UK proctoscope is called an anoscope;
this terminology is more accurate, but tradition rules), coupled with a barium enema to examine the remaining colon, may
be adequate. A better investigation is colonoscopy, which examines the whole colon in about 90 per cent of patients, or
flexible sigmoidoscopy, which views only the left colon. Both have therapeutic ability, in contrast to a barium enema. CT
colonograpy may be more commonly used in the future.
Colonoscopy was performed in this woman, and showed four small polyps scattered through the colon, and one 2 cm
pedunculated lesion in the distal left colon.
A6
With the therapeutic ability of colonoscopy, the polyp was removed with a diathermy snare cauterizing through the stalk.
The polyp was retrieved and sent for histology and showed a dysplastic polyp with no evidence of malignancy.
If the lesion had proven to be malignant, further treatment options would include advanced colonoscopic resection
(uncommon) or surgical resection of the involved colon. Being benign, one should consider the need for further
colonoscopy in the future – development of polyps makes further polyps more likely in future.
CASE 9.11 – ‘My bowel habit has changed.’
A1
Diverticular disease (diverticulosis)
Colitis
Left-sided colon cancer.
A2
Alteration of bowel habit is always significant over the age of 40 years, but benign causes such as diverticulosis are more
common than malignancy. Bleeding has not been a major feature, nor has pain or tenesmus (a feeling of incomplete
evacuation). The family history of colorectal cancer is of note, although the increase in cancer risk from baseline is only
moderate (three to six times).
A3
Some extracolonic cancers in family members may raise the possibility of hereditary non-polyposis colorectal cancer
(HNPCC), including endometrial, ovarian, stomach and pancreas, so take a careful family history. Ask about weight change.
296 General surgery
A4
Abdominal examination and DRE should be performed, followed by proctoscopy and sigmoidoscopy.
A5
Colonoscopy is the best investigation in this situation, although double-contrast barium enema may be performed in some
settings. Abdominal CT and CT colonography (‘virtual’ colonoscopy) are becoming more commonly used. Biopsy can be
performed with colonoscopy if suspicious masses or polyps are encountered.
Barium enema was performed in this man as a result of resource limitations at his health-care facility. This showed severe
diverticulosis in the sigmoid colon, with a comment that ‘small polyps in the sigmoid colon could not be excluded as a
result of the limitations of the study’. A subsequent flexible sigmoidoscopy of this area was performed and was normal.
A6
Supportive: given that there has been no complications of the diverticulosis, dietary management (with a high-fibre
diet) may reduce the risk of progression of this acquired condition. Many patients will, however, ultimately progress
and require specific treatment.
Medical: antibiotics may be required for infective complications of diverticular disease, either diverticulitis or peri-
diverticular abscess formation. (The latter may also be treated by percutaneous drainage under ultrasonic or CT
guidance.) Free perforation with peritonitis usually requires emergency operation.
Surgical: resection of the affected bowel segment (sigmoid colectomy) may be required in some patients, usually those
with repeated hospitalizations or complications. Severe diverticulitis with perforation may require emergency surgery,
either with a Hartmann procedure (resection of the diseased area with an end-colostomy; this may be joined up 6–12
months later) or resection and primary anastomosis after on-table colonic lavage.
CASE 9.12 – ‘It feels like I can’t finish my bowel motion.’
A1
Rectal cancer
Left-sided colon cancer
Severe diverticular disease.

A2
This history sounds ominous: the ‘funny’ feeling is called tenesmus and is characteristic of advanced rectal cancer. Weight
loss with objective findings as described is an important symptom.
A3
Again, a family history should be obtained. A thorough history (and particularly systems enquiry) will be required as a major
operation may be needed.
A4
Abdominal and rectal examination, with proctoscopy and sigmoidoscopy, should be performed. This reveals a large hard
rectal mass, and the liver is palpable and craggy. General examination is required to detect any other significant findings.
A5
A number of investigations are necessary. Biopsy of the mass may be done in the clinic, but is often done as part of an
examination under anaesthetic to determine tumour situation and fastness to surrounding structures. CT of the pelvis and
abdomen and MRI of the pelvis are often performed, with some centres also using endorectal ultrasonography or other
specialized imaging techniques. Colonoscopy should be performed to check for other polyps or tumours (synchronous
lesions).
A6
Supportive: nutrition is important and should be optimized. In widespread disease, or when curative treatment is
declined by the patient, palliative care measures such as pain relief are of critical importance.
Medical: little role.
Surgical: treatment is attempted with curative or palliative intent. Resection of the tumour is performed either through
the abdomen (anterior resection [of the rectum], sometimes with a temporary protective ileostomy), or via a combined
approach taking out the tumour and the anal canal in the perineum to leave a permanent end-colostomy
(abdominoperineal resection [of the rectum]). This may be done even in the presence of liver metastases in order to
minimize symptoms in the future. Rarely, resection of colorectal metastases in the liver is performed.
298 General surgery
Other: radiotherapy to the tumour in the pelvis may be performed as an extra (adjuvant) treatment combined with
surgery, and may be done before the operation to shrink the tumour or to reduce the incidence of local recurrence. If
the tumour cannot be removed, or the patient declines surgery, primary treatment with radiotherapy may provide
palliative benefit. Chemotherapy has a limited role in rectal cancer.

OSCE COUNSELLING CASE 9.7 – ‘What do I need to know about colonoscopy?’
A1
Colonoscopy is usually a safe procedure, but a number of issues need to be discussed. These include risks related to the
procedure itself and those related to the sedation that usually accompanies colonoscopy.
Perforation is extremely rare with diagnostic colonoscopy, and rises (but is still uncommon) with interventional procedures
such as polypectomy. Perforation is usually treated with antibiotics and active observation; surgery is rarely needed and
death from colonoscopy is almost unheard of. Significant bleeding is again very rare.
Failure of the procedure to obtain the information should be discussed. Rates of complete examination (sometimes
including intubation of the ileocaecal valve to visualize the terminal ileum) vary with experience but exceed 95 per cent in
many places. Despite excellent technique, lesions may sometimes be missed.
Operative risks specific to this procedure may be early or late.
Specific risks to consider in groin hernia repair are recurrence of hernia (i.e. failure of treatment), scrotal haematoma,
impairment of vascular supply to testicle (ischaemic orchitis) and late neuralgic pain from the wound.
Patients usually need to make a choice about whether to proceed with an operation based on their assessment of the risks
of the procedure versus the risks of the underlying condition. The best source of this information is the medical team, based
on published evidence (where present) or best opinions. There is a strong consensus that groin hernia should usually be
repaired surgically when present.
OSCE COUNSELLING CASE 9.8 – ‘Why are they talking about radiotherapy before
my bowel cancer operation?’
A1
Preoperative radiotherapy is used either where tumour shrinkage (‘down-staging’) is required to convert a borderline
resectable tumour to one that can confidently be removed, or to minimize the chance of local recurrence in operable but
advanced disease (i.e. invasion through the rectal wall or nodal involvement on imaging). A number of studies have now
shown a major reduction in local recurrence when preoperative radiotherapy is used appropriately.
A2
Radiotherapy risks can be considered as general and site specific. Common general side effects include tiredness (the
reason for which is poorly understood) and a local skin reaction such as sunburn.
Site-specific radiotherapy issues in the pelvis may include vaginal dryness in women, and impotence in men. The latter may
respond to agents such as sildenafil (Viagra). Most radiotherapy avoids the gonads and should not impair fertility. However,
sperm banking is an option for some to consider. Bladder or bowel inflammation can occur with radiotherapy, and some
degree of the latter is inevitable. In extreme cases, a diverting colostomy may be considered.
Late side effects can also occur and should be carefully discussed by the radiation oncologist.
300 General surgery
SURGICAL EMERGENCIES

Clinical cases
CASE 9.13 – An acute abdomen.
A 70-year-old man is brought into A&E complaining of abdominal pain. Over the last few months he had noted a change in
bowel habit and a loss of weight. On examination he is pale, tachycardic and hypotensive, and his abdomen is rigid on
palpation.
CASE 9.14 – Bowel obstruction.

A 60-year-old woman presents with a 2-day history of abdominal distension, pain, profuse bilious vomiting and
constipation.
Answers
CASE 9.13 – An acute abdomen.
A1
This man has an acute abdomen. The most likely diagnosis is a perforated viscus (probably colon). Other common causes
include pancreatitis, ruptured abdominal aneurysm, ischaemic bowel and non-surgical causes (myocardial infarct, lower
lobe pneumonia and diabetic ketoacidosis).
A2
The age of this man and a history of a change in bowel habit plus weight loss suggest a left-sided colonic neoplasm. The
sudden onset of pain could indicate a perforation, probably at the site of the tumour. If the tumour has been causing an
obstruction, the perforation can occur at a more proximal part of the colon – typically the caecum (the thinnest and widest
part of the large bowel and therefore the most easily distended). This requires a patent ileocaecal valve – producing a
closed loop obstruction. Right iliac fossa pain may be a warning of impending perforation in such cases and requires
action. Severe diverticular disease can cause a colonic perforation but does not usually cause weight loss. Free gas on the
plain radiographs and an acute abdomen will also be seen with a perforated duodenal ulcer, but is normally accompanied
by a history of peptic ulcer disease and patients tend to be less septic than those with a faecal peritonitis.
A3
Other factors that would point towards a colonic cancer include: any passage of fresh blood mixed in with the stool, a
family history of bowel and related cancers, previous colon cancer or inflammatory bowel disease.
A4
A full examination should be undertaken. Abdominal examination would be performed to assess which area is most tender.
Digital rectal examination may reveal a rectal tumour and should always be performed. A rigid, quiet abdomen would
suggest generalized peritonitis. A palpable node in the left supraclavicular area would suggest disseminated intra-
abdominal neoplasia.
302 General surgery
A5
An FBC may show anaemia secondary to bleeding from the tumour. Arterial blood gases would give an indication of the
degree of metabolic acidosis. Clotting parameters may be abnormal in the severely septic patient. Amylase and glucose
levels should be checked in all patients with an acute abdomen.
An erect chest radiograph may show free gas under the diaphragm, but its absence does not rule out a perforation. An
abdominal plain film may also show free gas. An abdominal CT can be performed if the patient is stable and there is some
confusion over the diagnosis.
A6
Initially the patient would be fluid resuscitated with several litres of colloid. Oxygen would be given via a facemask and a
urinary catheter is inserted to aid fluid management. A wide-bore nasogastric tube should be inserted if the patient is
vomiting. Thromboembolic deterrent stockings (TEDSs) should be applied. Opiate analgesia is given regularly. Low-
molecular-weight heparin should be given because of the high risk of thrombosis, but should be discussed with the
anaesthetist depending on the use of an epidural for postoperative pain management.
This patient requires surgery to treat the problem but all effort should be taken to optimize the patient, preferably in a high
dependency unit. The safest surgical option for a sigmoid perforation would be Hartmann’s procedure (sigmoid colectomy,
closure of rectal stump and formation of an end-colostomy). An alternative to this would be a resection of the sigmoid, an
on-table washout of the remaining colon and a primary anastomosis. This removes the need for a stoma and secondary
reversal procedure but does risk anastomotic breakdown and leak.
Faecal peritonitis carries a high mortality rate and good communication with the patient and family should ensure that they
are aware of this before surgery.
CASE 9.14 – Bowel obstruction.
A1
The most likely diagnosis is a bowel obstruction (probably small bowel). The common causes for this include adhesions,
hernias, malignancy and volvulus.
A2
The classic symptoms of small bowel obstruction (SBO) are the four symptoms given. The presence of profuse, bilious and
frequent vomiting suggests that this is caused by obstruction in the small bowel. If the vomiting were faeculent and
intermittent, a large bowel obstruction should be suspected (this requires a non-functioning ileocaecal valve to allow back
flow).
A3
The history would be aiming to assess the site of the obstruction (e.g. the patient with proximal SBO tends to have very
profuse, bilious vomiting and minimal distension, and can still be passing stool) and the cause. A history of previous
abdominal surgery, especially for abdominal malignancy, could be relevant.
A4
The examination may reveal the presence of an obstructing hernia. The degree of tenderness, especially localized, may
indicate impending bowel perforation in a closed-loop obstruction. Bowel sounds may be ‘tinkling’ or absent.
A5
A plain abdominal film will show dilated small bowel loops, occasionally with an obvious cut-off point. Arterial blood gases
may show some metabolic acidosis if the bowel blood supply is compromised. These can be difficult to interpret as a result
of the presence of a metabolic alkalosis secondary to vomiting. A contrast follow-through may be useful to differentiate
between partial and complete obstruction.
A6
Fluid resuscitation is essential because of the large volume of fluid lost into the bowel lumen (third space loss). A wide-
bore nasogastric tube will decompress the bowel. In a patient with no history of abdominal surgery or if an obstructing
hernia is identified, surgery should be performed after optimization. In those with suspected adhesional obstruction and no
physiological or biochemical evidence of bowel ischaemia, a period of intravenous fluids and nasogastric drainage (drip
and suck) can be undertaken to see whether it resolves spontaneously.
304 General surgery
VASCULAR: AORTIC ANEURYSM

Clinical cases
CASE 9.15 – ‘I thought I had gallstones. What is an aneurysm?’
A 55-year-old publican was sent by his GP for ultrasonography for suspected gallstones. The report shows no gallstones,
but comment is made about a 4.5 cm abdominal aortic aneurysm.
CASE 9.16 – ‘My doctor tells me that I need an operation on my aneurysm.’

The same patient has regular repeat scans. Three years later, the aneurysm has grown to 6.0 cm. He is referred to a
vascular surgeon; she recommends an operation to repair the aneurysm.
CASE 9.17 – Severe back pain and collapse with a known aneurysm.
A patient in the same practice is also known to have an aneurysm, measuring 6.0 cm in diameter. He was reluctant to have
an operation. He has had back pain for 2 days, which became severe this morning. Visiting the practice for pain relief, he
suddenly becomes clammy, yells in pain and collapses. An ambulance is called.

OSCE COUNSELLING CASE 9.9 – ‘What about this “stenting” I’ve heard about?’
A 57-year-old woman with a 5.5 cm aortic aneurysm has had treatment recommended to her. She does an internet search
and finds that there is a new treatment where the aneurysm is stented from the inside of the vessel, with almost
immediate recovery. Can she have this treatment instead?
OSCE COUNSELLING CASE 9.10 – ‘It’s not that serious. I couldn’t die from this
operation, could I?’
As part of the counselling and consent process, a patient becomes very concerned that he might die from the operation.
Surely this can’t be common?
Key concepts
Definition
This is a permanent localized dilatation (> 1.5 times normal) of an artery. A true aneurysm involves all vessel wall layers
(intima, media, adventitia), whereas a false aneurysm is a contained haematoma caused by disruption of the wall or leak
from an anastomosis.
Risk factors for aortic aneurysm
Although most aneurysms are thought to be a reflection of atherosclerosis (with the usual risk factors of smoking,
hypertension, diabetes, etc.), there is some evidence that it is a separate arterial disease. Elderly men who have brothers
with an aneurysm have a high incidence. The presence of popliteal or femoral aneurysms is a warning flag; they often
coexist.
What is the natural history?
The expansion rate of aneurysms is variable in individual patients, but most will enlarge with time at around 0.5 cm each
year. Rupture is uncommon below 5.5 cm and the patient is generally observed. The risk of rupture increases
disproportionately with increasing size.
306 General surgery
Answers
CASE 9.15 – ‘I thought I had gallstones. What is an aneurysm?’
A1
Although the diagnosis is clear, the aetiology has a differential diagnosis. Most aneurysms are degenerative; atherosclerosis
is usually present but not causative. Rarely pancreatitis or trauma can be a predisposing factor, as can syphilis (now
historical), other infections (TB) and connective tissue disorders.
A2
Male sex, age over 65, hypertension and smoking are the most important predisposing factors.
A3
Other manifestations of cardiovascular disease include coronary artery disease and peripheral vascular disease (PVD), both
of which have classic symptoms. There is a high rate of aneurysms in siblings (especially brothers) and this should be asked
about. Some suggest that any brothers be screened for the presence of aneurysms.
A4
Full cardiovascular and peripheral vascular examination should be performed including a BP measurement. Clinical
examination should include careful and gentle palpation of the abdomen – an aneurysm is characterized by ‘expansile
pulsation’ (where the examining fingers of both hands move laterally apart as well as anteriorly in time with the pulse).
Aneurysms may also occur in the same patient in the iliac, femoral and popliteal arteries, so these should also be checked.
A5
After detecting an aneurysm clinically or with ultrasonography, CT should be performed only if symptomatic or surgery is
being considered. Ultrasonography can be used subsequently for monitoring. Investigations should be aimed at assessing
predisposing factors. An ECG, cholesterol level, blood glucose and renal function should be assessed.
A6
For a small aneurysm (< 5.5 cm), observation is appropriate, with ultrasonography on a regular basis. Only 0.5 per cent will
rupture in any particular year, so the risk of this watch-and-wait approach is generally smaller than the risk of an operation.
Risk factor management is vital in such patients including controlling hypertension, hyperlipidaemia, diabetes and weight.
Patients can be started on aspirin.
CASE 9.16 – ‘My doctor tells me I need an operation on my aneurysm.’
A1–A4
As for Case 9.15.
A5
Computed tomography should be performed to disclose the maximal size, the configuration of the aneurysm and,
importantly, whether the origins of the renal arteries are involved (suprarenal aneurysm) or normal (infrarenal aneurysm).
The former is less common but poses a much more complex problem. More extensive assessment of fitness for surgery
should be undertaken to ensure that the patient is as fit as possible (e.g. cardiac stress test, respiratory function tests,
cardiac echocardiography).
308 General surgery
A6
There is a 40 per cent chance of rupture over the next 5-year period, and the average survival without treatment is
about 18 months. Options should be chosen with this in mind.
Do nothing at patient choice, or if the anaesthetic and operative risks are thought to outweigh the benefits.
Conventional operation: the aneurysmal segment of the aorta is replaced with a synthetic graft (Dacron) by
laparotomy. Death from the operation occurs in 5–8 per cent of patients.
Endoluminal stenting: a new technique suitable for some patients. Expanding stents are introduced via the femoral
arteries and carefully positioned inside the aneurysm. This technique is rapidly evolving.
CASE 9.17 – Severe back pain and collapse with a known aneurysm.
A1
Rupture of the aneurysm is most likely and must be assumed.
Other intra-abdominal catastrophes may mimic ruptured aneurysm: perforated ulcer in someone with known abdominal
aortic aneurysm (AAA); severe acute right heart failure with pulsatile tender hepatomegaly and pancreatitis.
A2
The prodromal pain of a contained leak is not uncommon. In the face of a known aneurysm, acute severe abdominal pain
demands immediate attention.
A3
It is unlikely that further history taking in this emergency situation would be helpful. A history from a family member may
be useful to ensure that inappropriate surgery is not attempted (e.g. if the patient has an advanced incurable malignancy).
A4
Clinical examination in this setting may reveal a pulsatile abdominal mass, but the absence of such a finding should not
dissuade emergency investigation and treatment. It is not uncommon for the abdomen to be rigid.
A5
Emergency CT may be considered if the patient is stable, but this should be only on the request of the operating vascular
surgeon. All patients should have blood taken for cross-matching (10 units initially plus fresh frozen plasma [FFP]). In most
centres, the patient would be taken to theatre for an emergency operation without any delays such as CT.
A6
Initial management should not include aggressive fluid resuscitation because this leads to greater blood loss by displacing
any clot present at the site of the rupture. A systolic pressure of 90–110 mmHg is optimum. The only effective treatment for
a ruptured aortic aneurysm is emergency repair. Rupture is highly lethal: as a rule of thumb, about half of the patients die
on the scene, half of the remainder die en route to hospital or in A&E, and half of those who make it to theatre
subsequently die.
310 General surgery

OSCE COUNSELLING CASE 9.9 – ‘What about this “stenting” I’ve heard about?’
Aortic stenting involves a vascular surgeon and/or radiologist inserting a balloon-inflated covered tube into the inside of
the weakened and dilated aortic wall, usually via a small incision in the groin. Placement is assisted using radiological
guidance. Although it can be faster and less invasive than open surgical treatment, stenting is not suitable for all patients
as a result of the aneurysm morphology. As a relatively new form of treatment, long-term outcomes are not known. In
addition, some new complications (‘endo-leak’) are recognized. There is a risk of on-table rupture during the procedure so
patients must be warned that a conversion to open surgery may be required. Only a few centres offer this form of
treatment, usually as part of a national trial.
OSCE COUNSELLING CASE 9.10 – ‘It’s not that serious. I couldn’t die from this
operation, could I?’
Depending on a number of factors, around 5–8 per cent of patients die from elective aortic aneurysm repair, and important
complications may occur in around 20 per cent. Both morbidity and mortality numbers can be modified – excellent
surgeons in excellent centres may achieve very good results, but selecting lower-risk patients will also appear to give the
same outcome.
Any operative and anaesthetic risk should be weighed against the risk of the disease itself. A 6 cm aneurysm has about a
40 per cent risk of rupture (with its high attendant mortality) over 5 years, and the median survival of a group of patients
with such an aneurysm is around 18 months.
PERIPHERAL VASCULAR DISEASE (PVD)

Clinical cases
CASE 9.18 – A 78-year-old man presents complaining of calf pain on walking.
A 78-year-old retired male teacher presents complaining of calf cramp in both legs on walking. This is worse on walking up
an incline. The pain disappears after a short rest period. This has been occurring for the last 3 months and does not appear
to be worsening.
CASE 9.19 – The same man presents to A&E with an acutely painful leg.
Clinically his leg is pale and cold.
Key concepts
Natural history
Intermittent claudication affects 5 per cent of men over 50 years of age.
5 per cent of those with claudication progress to critical ischaemia in a year.
75 per cent of those with claudication remain stable or improve.
Critical leg ischaemia
Persistently recurring ischaemic rest pain requiring regular adequate analgesia for > 2 weeks
Ulceration or gangrene of the foot or toes, with an ankle pressure of < 50 mmHg or toe pressures of < 30 mmHg
312 General surgery
Vascular imaging
Non-invasive imaging using duplex scanning (combining ultrasonography and Doppler images) and MR angiography (MRA)
has expanded as a result of the quality of the information and safety.
Digital subtraction angiography (DSA) is performed by a catheter being inserted into the opposite femoral vessels to the
limb being examined. This is then directed over the bifurcation to the other side (the Seldinger technique). The presence of
a catheter has the benefit of allowing therapeutic procedures to be undertaken such as angioplasty or inserting a stent.
Answers
CASE 9.18 – A 78-year-old man presents complaining of calf pain on walking.
A1
Peripheral vascular disease (PVD)
Spinal stenosis.
A2
The most likely cause will be PVD caused by atherosclerosis to the vessels to the lower limbs. The site of the stenosis or
occlusion will affect the presenting symptoms. The proximal disease (e.g. common iliac) may produce buttock claudication
on exercise as well as lower limb pain. The most common site to be affected is the obturator foramen (two-thirds of the
way down the thigh). This produces classic intermittent claudication (IC). The important aspects to obtain are the distance
walked before having to stop (remember that most patients and doctors are poor at judging this), the time required for the
pain to resolve and walking to recommence, and an assessment of the nature of the problem (static or progressive).
Spinal stenosis causes a similar presentation, making differentiation between the two sometimes tricky. Lower limb pain
from spinal stenosis tends to occur after varying distances walked and does not resolve within a few minutes of rest (unlike
in IC). The subsequent distances may become shorter and the time for resolution of the pain increases. The patient may also
complain of a ‘bad’ back with neurological symptoms.
A3
The diagnosis may be supported by the fact that the individual has risk factors that predispose him to atherosclerosis and
he may also have other cardiovascular problems.
A4
Full cardiovascular and peripheral vascular examination should be performed. The lower limbs may show signs of muscle
wasting, thinning of the skin, loss of hair and ulceration. Peripheral pulses may be felt at the groin but are absent distally.
314 General surgery
A5
In an individual not showing any signs of critical ischaemia or disabling claudication the investigations undertaken would
be aimed at preventing disease progression and not treating the stenosis or occlusion. Ankle brachial pressure indices
(ABPIs) should be recorded to allow quantitative comparison at future follow-up.
A6
Cardiac function should be optimized to decrease any ‘pump failure’ as a cause. Strategies to slow disease progression
should be undertaken (cessation of smoking, controlling hyperlipidaemia, good diabetic control). Anti-platelet medication
should be started to prevent thrombosis of the vessel.
Regular exercise improves neovascularization and cardiorespiratory function, and helps weight loss.
CASE 9.19 – The same man presents to A&E with an acutely painful leg.
A1
The patient appears to have developed acute limb ischaemia (ALI). This is commonly the result of either thrombosis of
diseased vessels or an embolus occluding the vessel. In a known sufferer of PVD the most likely cause is thrombosis.
A2, A3
Emboli need a source (the most common being thrombus within a fibrillating left atrium). Another clue to an embolus as a
cause is the presence of normal pulses on the contralateral limb. The known presence of a popliteal aneurysm would point
towards a thrombosis if now impalpable.
A4
An examination will need to assess the viability of the limb and the urgency for any intervention. Sensory and motor
function should be assessed and recorded. ABPIs should be performed. The patient’s general state should be assessed
because ALI is often a pre-morbid episode and surgical intervention may cause unnecessary suffering.
The viability of the peripheral veins should be noted because these are typically used in bypass grafts.
A5
Imaging of the arterial anatomy is required to identify the site and length of occlusion and the presence of distal vessels
(suitable for a graft to be attached).
A6
Depending on suitability, a bypass graft may be attempted to restore flow. If the limb is unsalvageable then an amputation
may be required.
316 General surgery
VASCULAR: CAROTID

Clinical case
CASE 9.20 – A previously well 39-year-old man attends A&E with a left-sided
headache and slight word-finding difficulty after a mild whiplash
injury 2 hours earlier.
He says the right arm doesn’t ‘feel right’. His wife has noticed a slight drooping of the eyelid on the left.
Vascular: carotid 317
Answer
CASE 9.20 – A previously well 39-year-old man attends A&E with a left-sided
headache and slight word-finding difficulty after a mild whiplash
injury 2 hours earlier.
A1
Dissection of the left carotid artery
Left-sided intracerebral haemorrhage
Migraine with aura
Cerebrovascular disease causing a left-sided stroke in the middle cerebral artery territory
The most likely cause is a dissection of the left carotid artery.
A2
Carotid artery dissection is a significant cause of stroke in patients younger than 40 years. Dissections are usually
subadventitial (between the media and adventitia or within the media), creating a false lumen that can cause stenosis,
occlusion or pseudoaneurysm of the vessel. Simultaneously, the dissection may cause the formation of a thrombus from
which fragments embolize. Strokes resulting from carotid dissection thus may have a haemodynamic or embolic origin.
As in this case, carotid artery dissections have non-specific presenting symptoms such as neurological deficits and
headache. They often occur at a relatively young age and in previously healthy individuals, either spontaneously or after
various degrees of trauma.
In this case a major clue to the cause of this patient’s stroke is that he has a painful drooping left eyelid that suggests the
possibility of Horner’s syndrome. Horner’s syndrome is caused by damage to the sympathetic supply to the eye. The
sympathetic fibres travel with the carotid artery and carotid dissection may damage these fibres. A Horner’s syndrome
consists of ptosis, miosis, enophthalmos and sometimes loss of sweating on one half of the face. It is important to consider
a carotid dissection in any case of painful Horner’s syndrome.
The patient is very young to have significant cerebrovascular disease. The other causes mentioned would not generally be
expected to cause Horner’s syndrome, but remain possibilities.
A3
If the patient does not have a previous or family history of migraine this reduces the possibility of migrainous aetiology.
318 General surgery
A4
Signs of an upper motoneuron pattern sensory–motor deficit in the right arm and signs of a Horner’s syndrome (see above)
should be found. It is also important to search for evidence of a head injury and, given the history of neck pain, to exclude
evidence of spinal cord damage (bilateral limb weakness and sensory loss).
A5
CT/MRI of brain
Non-invasive angiography of the carotid arteries
Invasive contrast arteriography.
Computed tomography of the brain will be adequate in most circumstances to demonstrate ischaemic damage in the
middle cerebral artery distribution, although MRI is more sensitive. Ultrasonography of carotid arteries is fast, convenient,
non-invasive and highly sensitive, and may identify a dissection. Invasive contrast arteriography is more accurate but carries
greater risk. Non-invasive alternatives include CT and MRA. ECG and echocardiography may be performed to rule out a
cardiac source of the emboli.
A6
Aspirin
Anticoagulation.
Formal anticoagulation for a period of months is often used, although the evidence base for this is relatively poor. In
practice the choice between anticoagulation agents and aspirin is made, dependent on various circumstances (e.g. how
severe the stroke is, the length of time since the dissection).
Venous disease 319
VENOUS DISEASE

Clinical case
CASE 9.21 – A 65-year-old woman has noticed a breakdown in the skin over her
left lower leg.
The lower limb is swollen and discoloured.
Key concepts
What is an ulcer?
It is a lesion on the surface of the skin or a mucous surface resulting in epi-/endothelial loss produced by the sloughing of
inflammatory necrotic tissue
What causes a venous ulcer?
Venous disease
Arterial disease
Neuropathy, e.g. secondary to diabetes
Malignancy
Underlying osteomyelitis
Inflammatory, e.g. pyoderma gangrenosum
Vasculitis.
Venous ulceration is a result of an increase in the venous pressure of the lower limb. Over time this leads to changes seen
to the ‘gaiter’ region of the leg. Chronic venous insufficiency is a term used to describe these changes, which are
characterized by pigmentation, lipodermatosclerosis (thickening of the skin), swelling, varicose eczema and ulceration. The
cause of this increased pressure is abnormalities to the flow caused by incompetent veins within this venous system, which
can result from a previous deep vein thrombosis (DVT).
320 General surgery
Answers
CASE 9.21 – A 65-year-old woman has noticed a breakdown in the skin over her
left lower leg.
A1, A2
Ulceration over the lower limb is a common problem with venous ulceration accounting for about 1 per cent of the NHS
budget
With unilateral discoloration and swelling, the most likely cause is chronic venous insufficiency. A mixed arteriovenous
condition should also be considered. Symptoms are exacerbated in elderly people by poor mobility, poor calf muscle pump
and dependency.
Consider trauma and cellulitis.
A3
The patient commonly remembers a trivial injury to the area that seemed to precipitate the ulcer. There may be a long
history of varicose veins, possibly with previous surgery and a family history of varicose veins. The history may demonstrate
either a known or risk factors predisposing to a DVT (e.g. lower limb immobilization within a plaster of Paris). Other factors
that may affect wound healing such as poor nutritional state, renal impairment, use of steroids and diabetes are not
uncommon in elderly people.
A4
A full venous examination must be performed with the patient standing. Abdominal examination should exclude
pelvic/abdominal mass.
Emphasize the peripheral pulses.

Venous disease 321
A5
A non-invasive assessment of the venous system of the limb should be performed. This will assess deep vein patency
and competence as well as saphenofemoral, saphenopopliteal and perforator competence. This assessment is most
commonly by duplex; however, hand-held Doppler in the outpatient clinic may be of use.
ABPI assessment is required if there is any suggestion of arterial disease (because it may require compression).
Arteriography may be required if arterial disease present.
If an atypical ulcer consider biopsy (vasculitic ulcer, Marjolin’s ulcer).
Assessment of oedema.
A6
Initial treatment will involve compression of the lower limb with four-layer compression bandages. Leg elevation is
recommended when sitting or lying. Surgery should be considered in those with a patent deep venous system, but
incompetence of the saphenofemoral, sphenopopliteal and/or perforators. Surgery does not increase speed of ulcer healing
but reduces recurrence rates.
Nutritional and vitamin supplementation may be required as well as optimization of any medical problems. Patient
education is essential to reduce recurrence.
322 General surgery
BREAST

Clinical Cases
CASE 9.21 – ‘I’ve found a breast lump.’
You are asked to see a 24 year old legal assistant who has noticed a lump in her breast over the last six weeks. She has not
previously had breast lumps, and there is no family history of breast cancer. Examination reveals a 2 cm diameter firm mass
lateral to her left nipple.
CASE 9.22 – ‘Something has shown up on my screening mammogram.’

A 53 year old woman is recalled for further imaging after her screening mammogram shows some ‘calcifications’. A
physical examination is unremarkable, with no lump palpable. A mammographic-guided stereotactic core biopsy is
obtained, and histology shows ductal carcinoma in situ (DCIS). Appropriate treatment needs to be arranged.
CASE 9.23 – ‘I’ve found a lump under my armpit.’

When this 62 year old woman discovers a hard lump under her right arm, she sees her GP the next day, and is referred to a
specialist Breast Unit. The finding is confirmed, and a hard 4 cm mass is also found deep to the nipple—the clinical
impression is of breast cancer. Fine-needle aspiration cytology confirms malignant cells, and mammographic and ultrasound
appearances support the diagnosis. Treatment options are discussed.

OSCE COUNSELLING CASE 9.11 – ‘What can I do for this breast pain?’
OSCE COUNSELLING CASE 9.12 – ‘I’m confused by my surgical options for breast
cancer. Which should I choose?’
Breast 323
Key concepts
In order to work through the core clinical cases in this chapter, you will need to understand the following key concepts:
How common is breast cancer?
Breast cancer is one of the most common female malignancies; you may hear that one in 12–14 women will get it.
Remember that this is a cumulative, lifetime risk that is age-dependent. Younger women are much less likely to develop
breast cancer, with the risk only slowly increasing with age.
My grandmother had breast cancer—will I get it too?
A number of factors will increase the risk of an individual developing breast cancer; some are rare but important (breast
cancer susceptibility genes such as BRCA1) and others are more common but variable. Family history is important when it
is a first-degree relative (sister, mother) and especially when the cancer was diagnosed pre-menopause or affected multiple
relatives. With a relatively common disease such as breast cancer, having more distant relatives with breast cancer is
usually just chance.
How is breast cancer managed?
Options for the diagnosis and treatment of breast cancer have expanded hugely over the last few years. Management in a
multidisciplinary setting (with radiologists, surgeons, pathologists, oncologists, and reconstructive specialists) ensures the
best outcomes for patients.
324 General surgery
Answers
CASE 9.21 – ‘I’ve found a breast lump.’
A1
Fibroadenoma
Fat necrosis
(Breast cancer—unlikely, but needs to be excluded).
Q2: What issues in the given history support your final diagnosis?
A2
The age of the patient makes fibroadenoma the most likely diagnosis, with other benign lesions also possible. Breast cancer
in this age group is extremely rare, but needs to be considered; a positive family history would increase one’s concern.
A3
Checking about trauma to the breast is useful, and may support a suspicion of fat necrosis.
A4
Clinical examination of both breasts (with a chaperone) should be performed. The axillary and supraclavicular nodal fields
should be checked.
A5
Investigations should be imaging and pathology to complete the ‘triple assessment’. Mammography is difficult to interpret
in the dense breasts of women under 35, and is usually not performed; ultrasound has greater diagnostic accuracy and is
the imaging modality of choice in this group. Fine-needle aspiration cytology for a palpable lump is easily performed, and
may be interpreted immediately by a pathologist in the clinic.
In this patient, clinical examination, ultrasound, and FNA are consistent and all support the diagnosis of fibroadenoma.
Breast 325
A6
The natural history of fibroadenomas is that about one third regress over time, one third remain the same, and one third
continue to grow. Women should understand this in order to make treatment choices.
Non-operative. Some women are reassured by a benign diagnosis, and prefer to avoid an operation. To minimise the risk
of the very rare false-negative diagnosis or missing a phyllodes tumour, most Breast Units would recommend obtaining
either a second definitely-benign FNA at another time, or obtaining tissue for histology (rather than cytology) by a core
biopsy, usually under ultrasound guidance.
Operative. Removal of the fibroadenoma is usually possible with a small scar, often placed along the areolar margin for
cosmetic reasons. This both confirms the diagnosis and treats the problem definitively.
CASE 9.22 – ‘Something has shown up on my screening mammogram.’
A1
Flecks of calcium on mammograms are reasonably common, and their likely diagnosis depends on their shape, size, and
number. Large calcifications are usually not associated with cancer, and some configurations of calcium deposition may be
pathognomonic, such as cup-shaped dependent calcium in cysts. In contrast, groups of small calcifications (‘clustered
microcalcifications’) may be associated with extra breast cell activity, usually benign, but sometimes in areas of early cancer
or DCIS.
A2
The lack of family history, or the presence of a lump, is now the most common presentation of breast cancer—screening
mammography is intended to identify breast cancer or DCIS early to allow earlier treatment. (Large studies have now
shown this is effective on a population basis, and most developed countries now have a screening program).
A3
Family history should again be determined for both breast and ovarian carcinoma; although useless to the patient herself,
this may have implications for her children if positive.
326 General surgery
A4
Breast examination is required, along with complete physical examination.
A5
The screening mammogram should be reviewed, and sometimes further imaging workup (mammography and ultrasound)
is required. Any previous screening films should also be reviewed and audited to assess if the lesion was identifiable earlier.
As the lesion is not palpable, a mammographic or ultrasound guided stereotactic core biopsy should be obtained.
Subsequent histology of the stereotactic core biopsy shows ductal carcinoma in situ (DCIS).
A6
Treatment options for DCIS are wide local excision (WLE) if well-localized, or mastectomy if covering a large area or multi-
focal. To aid excision of an impalpable lesion, a wire is placed with the tip adjacent to the area needing removal. Axillary
node dissection (AND) is not performed for in-situ disease due to the minimal risk of nodal spread. DCIS may widely ramify
in the breast, so surgical margins need to be thoroughly examined to ensure clearance. Further excisions may be required
to obtain this. In high-grade or extensive DCIS there is evidence that radiotherapy reduces the rate of local recurrence. Half
of all recurrences will be invasive so it is vital to perform optimal treatment. Immediate reconstruction should be offered to
any woman undergoing a mastectomy.
CASE 9.23 – ‘I’ve found a lump under my armpit.’
A1
Diagnosis is secure, but attention should be directed to the presence of any symptoms suggestive of distant metastatic
spread.
A2
See above
Breast 327
A3
See above
A4
Complete physical examination should search for metastases.
A5
Investigations should focus on staging the disease, and determining risk factors for anaesthesia.
A6
Unless the patient chooses a non-operative approach, surgery is required and is often supplemented by radiotherapy,
chemotherapy, hormonal manipulation, or a combination of these. In a women presenting with proven nodal disease and a
tumour unsuitable for WLE, chemotherapy can be given prior to surgery (neo-adjuvant treatment). This has the benefit of
reducing the size of the tumour, allowing breast-conserving surgery and also demonstrating the efficacy of the chemotherapy.
In patients with extensive co-morbidities, that prevent surgical treatment, neo-adjuvant endocrine treatment can be used.
Surgical. The operation is performed for local control of disease, and to obtain prognostic information about the tumour
that may tailor subsequent treatment. The main choice to be made is between WLE (with radiotherapy to the remaining
breast) and mastectomy, either of which are accompanied by axillary node dissection. These offer equivalent survival
outcomes, and should usually be the choice of the patient. Reconstructive surgery should ideally be offered to the patient
considering mastectomy, and options include immediate or delayed reconstruction, and the use of implants or endogenous
tissue (such as the transverse rectus abdominus myocutaneous (TRAM) flap or the latissimus dorsi flap). Axillary dissection
is undergoing re-evaluation, and many units are now studying whether a sentinel node biopsy (SNB) may provide adequate
staging information without the morbidity of completely removing the lymph nodes under the arm, which has a degree of
morbidity. This is not appropriate in a woman with proven nodal disease.
Radiotherapy is used where wide local excision (WLE) is performed, but may also be offered for aggressive tumours. This
may be directed to the chest wall, axilla and supraclavicular regions.
Chemotherapy is offered for aggressive tumours to reduce the risk of metastatic disease. Patients with positive lymph
nodes are usually considered for chemotherapy, but node-negative patients with large, high-grade tumours, or younger
patients, also benefit.
Hormonal manipulation is given in patients who have hormonally sensitive tumours (oestrogen and/or progesterone
receptor positive). Tamoxifen (which binds to the oestrogen receptor) has been joined by the aromatase-inhibitor group of
drugs (preventing androgens being coverted to oestrodiol). These greatly reduce cancer recurrence and are well tolerated.
328 General surgery

OSCE COUNSELLING CASE 9.11 – ‘What can I do for this breast pain?’
Breast pain is surprisingly common amongst women. It may be cyclical or non-cyclical, and a careful history will determine
the timing and any trigger factors. After history and examination has excluded any other aetiology, options for breast pain
can be discussed. Most women will cope with the discomfort on being reassured there is nothing sinister causing the pain.
The importance of a correctly-fitted bra should be emphasised, and specialised sports bras may be useful for periods of
vigorous exercise. The two most important avoidable factors in true breast pain are smoking and caffeine intake, and a
breast pain presentation is a valuable opportunity to reinforce smoking cessation advice.
Simple analgesics may be appropriate if the pain is pronounced only during part of the menstrual cycle. Some women find
Evening Primrose Oil useful—this needs to be taken in moderately high doses and for a prolonged period before the peak
benefit is obtained, but has very few side effects and does not require a prescription.
OSCE COUNSELLING CASE 9.12 – ‘I’m confused by my surgical options for breast
cancer. Which should I choose?’
For most women (except those with very advanced tumours), it has been determined by a number of well-performed
studies that breast-conserving surgery—i.e. Wide local excision (WLE) followed by radiotherapy to the remaining breast—
results in equivalent overall survival to mastectomy, and a similar incidence of local recurrence. Accordingly, the choice of
operation should be the patient’s. Whatever approach is used, it should be made clear to the woman that she will be
supported with as much information as she feels is needed to make a decision.
Many women feel that time is critical, and they want to have their operation as soon as possible. It is worth emphasising
that breast cancer is usually a slowly growing tumour, and by diagnosis it may have been present for many months or even
years. Allowing some days or a week or two to make a decision will not jeopardise the outcome, but may allow un-
pressured choices to be made.
Mastectomy has a major impact on the body image of most women. For women who choose mastectomy (or for whom
WLE is not appropriate for some reason), reconstructive surgery should usually be discussed and offered. Very rarely,
resource constraints limit choices—if either radiotherapy or reconstructive surgery is available, mastectomy remains an
excellent operation from the cancer point of view, but this is clearly suboptimal in the overall care of the patient.
Axillary node staging gives prognostic information that influences adjuvant treatment . Sentinel lymph node biopsy is a
technique of identifying the first node that drains the breast. This is performed using a blue dye and radio-active colloid.
This has the significant benefit of reduce post-operative morbidity when compared to axillary node clearance or sampling. If
this node is clear the presumption is there has been no spread to the axillary nodes. Unfortunately its sensitivity is not
100 per cent, plus if the node is positive it usually requires a full axillary block dissection or axillary radiotherapy.
Index
abdominal bloating/swelling 233, adenoma–carcinoma sequence anoscopy 294
234, 235–6, 253, 255 293 anti-endomyseal antibodies 261,
abdominal pain adhesions, small bowel 302–3 262, 264
acute abdomen 300, 301–2 adrenal failure 49–53 anti-glomerular basement
aortic aneurysm 308–9 adrenocorticotrophic hormone membrane antibodies 98
appendicitis 284–91 (ACTH) 50, 51, 53, 54–7 anti-phospholipid syndrome 51
bowel obstruction 300, 302–3 AF see atrial fibrillation anti-platelet medication 314
colorectal cancer 292 Af see atrial flutter anti-rheumatoid drugs 66, 70,
constipation 240 agitation 156–8 75
diabetes 35, 38 albuminuria 22, 27, 28, 31–2 anti-tumour necrosis factor
gallstones 276, 278–90 alcohol abuse therapy 75
inflammatory bowel disease acute confusional states 156, antibiotics
219, 221–3 160–1 appendicitis 287, 290
irritable bowel syndrome 255 cirrhosis 233 bronchiectasis 198
jaundice 249 hepatitis 248, 250, 251 cholecystitis 280
pancreatitis 212, 215–17, oesophageal varices 209–10 encephalopathy 237
218 pancreatitis 212, 214, oesophageal varices 210
ABPIs see ankle brachial 216–18 peptic ulcers 227, 230
pressure indices tuberculosis 193, 194, 198, pneumonia 188
absolute risk/relative risk 201 resistance 199, 201, 237
concepts 211, 225 ALI see acute limb ischaemia tuberculosis 199, 201
ACE see angiotensin-converting allopurinol 74 anticholinergics 169, 244, 245
enzyme ALS algorithm 118 anticoagulation
5-acetylsalcylic acid (5-ASA) 209 Alzheimer’s disease 161–2, 163 carotid artery
acid suppression 214 American College of dissection/stroke 318
ACR see American College of Rheumatology (ARC) 80 prosthetic heart valves 130,
Rheumatology amiodarone 114 131
acromegaly 59–62 amoebic liver abscess 249, 250 pulmonary embolism 187, 192
ACTH see adrenocorticotrophic amyloidosis 96 stroke 151
hormone anaemia 100, 260, 261, 262–3, antiviral therapy 248, 251, 252
acute abdomen 300, 301–2 266, 289 aortic aneurysm 304–10
acute appendicitis 286–7 aneurysms 272, 304–10 aortic dissection 127–8
acute cholecystitis 279–80 angina 113–14, 124, 131, 132, aortic regurgitation 120
acute confusional states 156–64 137 aortic stenosis 120, 137–8
acute glomerulonephritis 98 angiotensin II receptor blockers appendicitis 284–91
acute limb ischaemia (ALI) (ARBs) 30–1, 95, 101, 114 ARBs see angiotensin II receptor
314–15 angiotensin-converting enzyme blockers
acute pancreatitis 215–16 (ACE) inhibitors ARF see acute renal failure
acute renal failure (ARF) chronic heart failure 113, 132 arrhythmias, cardiac 115–17,
103–10 diabetes 30–2 123
acute tubular necrosis (ATN) renal impairment 95, 101, arterial bypass grafts 315
104, 106 103, 107 arterial disease 304–18, 319,
acute-on-chronic confusional stroke patients 151 321
state 161–2, 163 ankle brachial pressure indices arteritis 79
acute-on-chronic renal (ABPIs) 311, 314, 315, arthralgia 65
impairment 107 321 arthritis 59, 64–77, 79, 150–1
Addison’s disease 49–53 ankylosing spondylitis 87–8 5-ASA see acetylsalcylic acid
adenomas 54–8, 59–62 anorexia nervosa 263 asbestosis 180–1
330 Index
ascending cholangitis 279–80 bowel cancer valvular disease 120–2,

ascites 234, 235–6 coeliac disease 261, 264–5 129–30, 131
ASD see atrial septal defect colon 292, 293, 295–6, cardiomyopathy,
aspirin 33, 226, 228, 232, 318 301–2 haemochromatosis 214
see also non-steroidal anti- rectal 292, 293, 296–8 cardiopulmonary resuscitation
imflammatory drugs ulcerative colitis 225 (CPR) 112, 118, 126
asthma 176–7, 178–9 bowel function cardiovascular disease
atherosclerosis 305, 313 see also diarrhoea chronic renal failure 95, 101
ATN see acute tubular necrosis constipation 148, 150, 151, diabetes 5, 6, 28–33
atrial fibrillation (AF) 115, 116, 153, 240–6, 300 rheumatoid arthritis 67
123–4, 139–41, 161–2, elderly people 148, 150, 151, Carney complex 61
214 152, 153 carotid artery dissection 316–18
atrial flutter 115, 116 faecal impaction 150, 152, carpal tunnel syndrome (CTS)
atrial septal defect (ASD) 122 153, 169–70 23–4, 59
atrioventricular (AV) block 117 habit changes 292, 294, 295, cataract 21
autoimmune adrenal failure 300 cerebral oedema 34
49–53 incontinence 165, 167, cerebrovascular disease 28, 317
autoimmune diseases 53 169–70, 240, 244–5 cervical myelopathy 140, 141,
autoimmune hepatitis 249, 250 bowel obstruction 273–4, 289, 148–9
AV see atrioventricular 300, 302–3 CFA see cryptogenic fibrosing
axillary node dissection 326, BP see blood pressure alveolitis
327, 328 BPH see benign prostatic Charcot’s triad 280
hypertrophy chemotherapy 327
breasts 322–9 chest pain 112, 119, 124, 127,
ß blockers 114, 131, 132 British Thoracic Society (BTS) 185 183–92, 195
ß-cell failure 11, 17 bronchial carcinoma 195–6, 198 children 68–9, 96
back pain 85–9, 308–9 bronchiectasis 178, 196–8 chiropodists 25–6
bacterial overgrowth 255 bronchitis 145, 150–1 cholecystectomy 279, 280
balance 136 cholestatic jaundice 249
barium enemas 244, 295 cholesterol 29
barium follow-through 264, 265 C-reactive protein (CRP) 64, 66 chronic confusion 161–4
barium meals 227, 231 caecal cancer 289 chronic heart failure 113–14, 132
benign colorectal polyps 293, calcifications in breast 322, chronic hepatitis 247–8
294–5, 299 325–6 chronic kidney disease 94–102
benign hypermobility 68–9 calcium chronic liver disease 205,
benign prostatic hypertrophy antagonists 148 209–10
(BPH) 270, 273, 275 hypercalcaemia 142, 161, chronic obstructive pulmonary
bile ducts 277, 279–80 242–3 disease (COPD) 145,
biliary colic 215, 216, 276, 277, hypocalcaemia 144 150–1, 178–9, 182
278 supplements 135, 144 chronic pancreatitis 214–15,
biofeedback 258 carbimazole 46–7 216–18
biopsy carbon monoxide (CO) chronic renal failure (CRF) 95
breast lumps 325, 326 poisoning 161–2 chronic venous insufficiency
coeliac disease 261, 262, 264 carcinoma 319–21
hepatitis 251, 252 breast 322–3, 325–8, 328 cirrhosis 233–9
sentinel node 327, 328 bronchial 195–6 claudication 311–14
systemic rheumatological coeliac disease 261, 264–5, Clostridium difficile 169–70,
illnesses 81, 83 266 207, 208, 211
bisoprolol 113, 132 colorectal 292–9 CO see carbon monoxide
bisphosphonate 144 hypercalcaemia 242 co-danthromer 243
bladder neck obstruction 92–3, liver metastases 235, 297 coeliac disease 260–6
99 obstructive jaundice 280–1 cognitive impairment 157,
bladder problems 166, 168–9 stomach 206, 228–9, 230–1 161–2, 163, 168
blood pressure (BP) cardiogenic pulmonary oedema colectomy 208–9, 222
see also hypertension; 180 colicky pain 215, 216, 219, 222,
hypotension cardiology 111–32 276–8
control 13–14, 22, 30–1, 33, arrhythmias 115–17, 123, 137 colitis see inflammatory bowel
95, 109–10 cardiac arrest 118–19, 126–7 disease; ulcerative colitis
bone mass 89 heart failure 113–14, 132, colon cancer 292, 293, 295–6,
bony metastases 242 157, 161–2 301–2
Index 331
colonic dysmotility 243, 244 pulmonary embolism 186 DMARDs see disease-modifying
colonoscopy 295, 296, 299 stroke patients 151, 152, 153 anti-rheumatoid drugs
colorectal cancer 292–9, 301–2 venous ulcers 319, 320 DOT see directly observed
colostomy 225 dehydration 141–2, 242 therapy
coma 35 delirium 157 Driving and Vehicle Licencing
community-acquired pneumonia delirium tremens 160–1 Agency (DVLA) 9
184, 185, 187 dementia 161–3, 165, 169 drug abuse 5, 157, 247, 248,
compliance 199–200, 264–5 depression 54–6, 151, 154, 244 250–1
computed tomography (CT) 307 DEXA see duel energy X-ray drugs, see also medication
confusion absorptiometry problems
acute confusional states diabetes 1–42 DSA see digital subtraction
156–64 acute confusional states 156, angiography
chronic 161–4 159 ductal carcinoma in situ (DCIS)
community-acquired diagnosis 2–9 322, 325–6
pneumonia 185, 188 emergencies 34–42 duel energy X-ray
decompensated liver disease glucose control 7–8, 10–18, absorptiometry (DEXA) 86
233, 236–7, 239 42 duodenal tumours/polyps 230,
hypercalcaemia 242 large vessel complications 231
incontinence 169 27–33 duodenal ulcers 206–7, 227,
connective tissue disorders pancreatitis 214 228–9, 301
78–81, 84 renal failure 93, 96, 102 DVLA see Driving and Vehicle
constipation 148, 150, 151, small vessel complications Licencing Agency
153, 240–6, 300 19–26 DVT see deep vein thrombosis
continuous subcutaneous insulin diabetic ketoacidosis (DKA) 35, dysmotility syndrome 231
injections 17–18 38–40, 42 dyspepsia 226, 229
COPD see chronic obstructive dialysis 102, 105 dyspnoea 174–82
pulmonary disease diarrhoea asthma 176–7
cor pulmonale 150–1 appendicitis 286 chronic obstructive pulmonary
coughing coeliac disease 263 disease 178–9
asthma 176 giardiasis 256–7 fibrotic lung disease 180–2
bronchiectasis 196–8 inflammatory bowel disease pneumothorax 189–91
chronic obstructive pulmonary 204, 207–9, 211, 219, renal disease 103, 108–9
disease 174, 178 223 dysuria 92, 99
haemoptysis 81, 183, 186, irritable bowel syndrome 253,
193–201 255, 256–7
CPR see cardiopulmonary overflow 169–70, 244–5 early onset type 2 diabetes 7
resuscitation pancreatitis 212, 214 elderly people 133–72
creatinine clearance 92, 93–4, renal disease 103, 106 acute confusional states
95 diet 156–64
CRF see chronic renal failure anaemia 262 arthritis 71, 73–4
critical leg ischaemia 311, chronic kidney disease 102 bowel cancer 292, 296–8,
314–15 chronic pancreatitis 214 300–2
Crohn’s disease 223–4, 263, coeliac disease 263 diabetes 4–5, 13–15, 21,
289, 290 constipation 241, 243–4 30–1, 36–8
CRP see C-reactive protein diabetes 4, 6, 9, 11, 13, 29 falls 134–44, 170
cryptogenic fibrosing alveolitis diverticulosis 296 heart problems 126–7, 131–2
(CFA) 175, 180–2 gallstones 278–9 hernias 269, 272–4
crystal arthritis 73–4 stroke patients 152, 153 immobility 145–55
CTS see carpal tunnel syndrome venous ulcers 321 incontinence 165–72
Cushing’s disease 54–8 digital subtraction angiography osteoporosis 86–7, 89
(DSA) 312 peptic ulcers 206–7, 228–9
direct hernias 271 peripheral vascular disease
DCIS see ductal carcinoma in directly observed therapy (DOT) 311–15
situ 200, 201 renal disease 99, 107–9
deafness 157 disease-modifying anti- respiratory problems 174–5,
decompensated liver disease rheumatoid drugs 178–82, 187–9
233–9 (DMARDs) 66, 70, 75 vasculitis 82–3
deep vein thrombosis (DVT) diuretics 107, 113, 168 venous ulcers 319–21
immobility 148–9 diverticular disease 295–6, 301 electrolyte imbalance 159, 160,
postoperative 146, 154, 268 DKA see diabetic ketoacidosis 236–7
332 Index
embolism feet 23, 25–6, 311 genetic factors 211, 323

carotid dissection 317 femoral aneurysms 272, 305 GFR see glomerular filtration
peripheral vascular disease femoral hernias 271, 273–4 rate
314–15 fertility 48, 81, 84, 260, 263 GH see growth hormone
pulmonary 176, 184, 186, fibroadenoma 324–5 giardiasis (Giardia lamblia) 256–7
192, 196, 268 fibrotic lung disease 180–2 gigantism 59
emergencies fine-needle aspiration cytology gliclazide 10, 11, 14–15
acute abdomen 300–2 322, 324 glomerular filtration rate (GFR)
bowel obstruction 300, finger-prick glucose test 2, 3 94
302–3 fludrocortisone 51–2 glomerular damage 104
diabetes 34–42 focal segmental glomerulonephritis 97, 98
gastroenterology 203–11 glomerulosclerosis (FSGS) glucagon injection kits 40, 42
obstructed hernia 273–4 96 glucocorticoids 49–53, 54–8
postoperative complications folate deficiency 261 glucosamine 68, 77
268 food allergy 260–6 glucose control 7–8, 10–18, 42
renal disease 103–10 four Bs of postoperative glucose tolerance testing 3, 4
ruptured aortic aneurysm complications 268 gluten allergy 260–6
308–9 fractures 85, 86–7, 135, 136, 144 glycaemic control tests 5, 7, 14
emphysema 145, 150–1 FSGS see focal segmental glyceryl trinitrate (GTN) 124, 131
encephalopathy 236–7, 238 glomerulosclerosis glycosuria 2, 3, 4
end-stage renal failure (ESRF) furosemide 109 gout 73–4
93, 94 Graves’ eye disease 44–8
endocrinology 43–62 groin hernias 269–75
acromegaly 59–62 gallbladder infections 279–80 growth hormone (GH) 59–62
Addison’s disease 49–53 gallstones 213, 215–16, 218, grumbling appendicitis 286
Cushing’s disease 54–8 276–83 GTN see glyceryl trinitrate
hyperthyroidism 44–8 gangrene 311 gynaecological pathology 287–8
endoscopic retrograde gastric cancer 206, 228–9,
cholangiopancreatography 230–1, 235
(ERCP) 216, 277, 281–2, gastric outlet obstruction 229, haematemesis 204, 205,
283 230–1 209–10, 233, 237–8
endoscopy 210, 227, 231, 238 gastric ulcers 206, 227–8 haemochromatosis 214
epilepsy 135, 144, 152, 156, 160 gastroenterology 203–66 haemodialysis 102
epithelial neoplasia 292–9 see also bowel. . . haemoptysis 81, 183, 186,
ERCP see endoscopic retrograde appendicitis 284–91 193–201
cholangiopancreatography bowel obstruction 302–3 haemorrhage 268
ESRF see end-stage renal failure cirrhosis 233–9 haemorrhoids 257–8, 294
eye problems coeliac disease 260–6 HBGM see home based glucose
ankylosing spondylitis 87–8 colorectal cancer 292–9, monitoring
diabetic retinopathy 6, 8, 20, 301–2 head injuries 141–2, 159, 160
21 constipation 148, 150, 151, headache 316
Graves’ disease 44–8 153, 240–6, 300 heart failure 113–14, 132, 157,
Horner’s syndrome 317 emergencies 204–11 161–2
hyperthyroidism 44–8 gallstones 213, 215–16, 218, heart murmurs 112, 120–2,
rheumatoid arthritis 67 276–83 129–30, 134, 138
vasculitis 79, 81, 82–3 hepatitis 247–52 Heberden’s nodes 67
visual disturbance 4, 21, inflammatory bowel disease Helicobacter pylori 207, 227–32
139–41, 157 204, 205, 207–9, 211, heparin 154
219–25 hepatitis 247–52
irritable bowel syndrome hernias 269–75, 302–3
faecal impaction 150, 152, 153, 253–9 hip problems 87, 136, 150–1
169–70 pancreatitis 212–18 hirsutism 54–6
faecal incontinence 165, 167, peptic ulcer disease 205, home based glucose monitoring
169–70, 240, 244–5 206–7, 216, 226–32 (HBGM) 14
faecoliths 285 general surgery 268–328 HONK see hyperosmolar, non-
falls, elderly people 134–44, appendicitis 284–91 ketotic coma
170 colorectal cancer 292–9 hormonal manipulation 327
familial risk factors 211, 266, gallstones 276–83 hormone disturbance 263
295, 306, 323 hernias 269–75 Horner’s syndrome 317
fat necrosis 324 risks 268, 275, 291 hydralazine 114
Index 333
hydrocortisone 51–2, 208, 221 indirect hernias 271 lactose intolerance 255, 256
hypercalcaemia 142, 161, infections laparoscopy 278, 279, 288,
242–3 see also UTIs 290, 291
hypercortisolaemia 54–8 acute confusional states 157, large bowel obstruction 302
hyperglycaemia 35, 38, 159 159, 160, 161, 163 large vessel disease, diabetes 4,
hyperkalaemia 50, 103, 107–8 bronchiectasis 197–8 5, 6, 20, 27–33
hypermobility 68–9 chronic kidney disease 101 laxatives 243, 244, 246
hyperosmolar, non-ketotic coma diabetes 4 leg problems
(HONK) 35, 36–8 diarrhoea 169–70, 207, 211, see also deep vein
hypertension 244–5 thrombosis
acromegaly 60, 62 gastrointestinal emergencies oedema 92, 96, 145,
aortic aneurysm 305, 306 205, 211 148–50, 153
Cushing’s disease 54–6 irritable bowel syndrome 254 peripheral vascular disease
diabetes 6, 13–14, 22, 30–1, obstructed hernia distinction 311–15
33 274 ulceration 145, 148–50, 153,
renal impairment 95, 100, postoperative 268 311, 313, 319–21
103, 109–10 infectivity risk, tuberculosis 199, lethargy 2, 4, 36, 49–51
hypertensive nephrosclerosis 95 200, 201 limb contractures 153
hyperthyroidism 44–8, 161 inflammatory bowel disease lipid levels 6, 28, 29
hyperuricaemia 73 (IBD) 204, 205, 207–9, Littre’s hernia 270
hyperventilation 176 211, 219–25, 255 liver disease
hypoalbuminaemia 96 inguinal hernias 269–75 alcohol abuse 160, 199, 201,
hypocalcaemia 144 injuries 233, 235, 239
hypoglycaemia 8, 9, 35, 40–1, acute confusional states 157, cancer metastases 235, 297
42, 160–1 159, 160, 163 cirrhosis 233–9
hyponatraemia 50, 160 carotid artery dissection hepatitis 247–52
hypotension 268 316–18 varices 205, 209–10
hypothermia 161 deaths 136 loose stools see diarrhoea
hypoxia 157 head 141–2, 159, 160 low-molecular weight (LMW)
insulin resistance 11 heparin 154
insulin treatment lumps, breast/armpit 322–9
IBD see inflammatory bowel continuous subcutaneous lupus see systemic lupus
disease injection/pumps 17–18 erythematosus
IBS see irritable bowel syndrome HONK 37 lymphadenopathy 228, 230,
ibuprofen 226, 228 type 1 diabetes 7, 17–18, 265, 271–2
IC see intermittent claudication 39–40, 42 lymphoma, small bowel 261,
IFG see impaired fasting type 2 diabetes 11–12, 264–5
glycaemia 16–17
IgA nephropathy 97 insulin-dependent diabetes see
IGT see impaired glucose type 1 diabetes mellitus magnetic resonance
tolerance intermittent claudication (IC) cholangiopancreatography
IHD see ischaemic heart disease 311–14 (MRCP) 277
ileoanal pouches 225 interstitial lung disease 180–2 malignancy
immobility 145–55 intussusception 222, 223 see also carcinoma
constipation 244 iritis 85, 87, 88 cirrhosis 235
faecal incontinence 153, 167 iron deficiency 261, 262 Cushing’s disease 54–5
stroke 151–5 irritable bowel syndrome (IBS) small bowel obstruction 302–3
urinary incontinence 148, 243, 253–9 mammograms 322, 325–6
152, 153, 166, 168 ischaemia, hernias 270, 273–4 Marfan’s syndrome 190
venous ulcers 320 ischaemic heart disease (IHD) mastectomy 326, 327
impaired fasting glycaemia (IFG) 28, 124 maturity onset diabetes see type
3, 4–5 2 diabetes mellitus
impaired glucose tolerance (IGT) Meckel’s diverticulum 270
3, 4–5, 28 jaundice 235, 249, 276, 279, MedicAlert 52
incontinence 280–2 medication problems
faecal 165, 167, 169–70, joint aspiration 72, 73, 76 acute confusional states 157,
240, 244–5 159, 163, 164
urinary 148, 151, 153, constipation 241, 242–3, 244
165–72 ketoacidosis 35, 38–40 falls 139–41
indigestion 226, 228–30 ketonuria 2, 7, 8, 34, 38 nephrotoxic agents 101–2
334 Index
medication problems – contd nephropathy Paget’s disease 61

NSAIDs 101, 108, 206, 207, diabetic 6, 8, 20, 22, 25 pain
226–9, 232 gout 73, 74 see also abdominal pain
opiates 242–3, 246 nephrotic syndrome 96 acute confusional states 163
melaena 204, 205, 206, 236, nephrotoxic agents 101–2 back 85–9, 308–9
238 neurological problems breast 328
membranous nephropathy 96 bladder control 166 calf 311–15
MEN-1 see multiple endocrine diabetic neuropathy 6, 8, 20, chest 112, 119, 124, 127,
neoplasia type 1 23–4 183–92, 195
menorrhagia 262 falls 139–41 colic 215, 216, 219, 222, 276–8
metformin 11, 13, 15 rheumatoid arthritis 67 joints 64–5
methicillin-resistant neuropsychiatric problems, shoulder 152, 153
Staphylococcus aureus Cushing’s disease 55 palpitations 44–7, 112
(MRSA) 237 nitrate medication 114, 124, 131 pancreatic carcinoma 280–1
MI see myocardial infarction nocturia 92, 99, 212, 214, 270, pancreatitis 212–18, 277
microalbuminuria 27, 28, 31–2 275 paracentesis 234, 236
microscopic haematuria 92, 97, non-alcoholic steatohapatitis parkinsonism/Parkinson’s disease
98 (NASH) 250–1 141–3, 156, 159–60, 165,
microscopic polyangiitis 98 non-insulin-dependent diabetes 169–70, 244–5
mineralocorticoids 50, 51–2 see type 2 diabetes PE see pulmonary embolism
Mini Mental State Examination mellitus pelvic abscess 285, 291
(MME) 185, 188 non-steroidal anti-inflammatory pelvic floor 166, 170
minimal change nephropathy 96 drugs (NSAIDs) peptic ulcer disease 205, 206–7,
miscarriage 183, 186, 192 osteoarthritis 68 226–32, 237–8, 301
missed appendicitis 289–90 peptic ulcer disease 206, perforated appendix 285, 289–90
mitral regurgitation (MR) 121 207, 226–9, 232 perforated bowel 301
mitral stenosis 121 renal impairment 101, 108 peri-diverticular abscesses 296
mitral valve prolapse (MVP) 121 non-ulcer dyspepsia 229–30 perianal abscesses 219, 223–4
MME see Mini Mental State NSAIDs see non-steroidal anti- peripheral vascular disease
Examination inflammatory drugs (PVD) 28, 311–15
monoarthritis 71–7 nutrition see diet peritoneal dialysis 102
mouth ulcers 262, 263 peritonitis 234, 236, 268, 285,
MR see mitral regurgitation 290, 301–2
MRCP see magnetic resonance obesity 11, 13, 17, 55, 250–1 phenytoin 144
cholangiopancreatography obstructive jaundice 280–2 physiotherapy 68, 77, 152, 154–5
MRSA see methicillin-resistant obstructive sleep apnoea 59, 60 pigmented skin 49, 50
Staphylococcus aureus occupational therapy 152 pioglitazone 11
mucosal prolapse 257–8 oedema pituitary adenomas 54, 57, 58,
mucus in stools 257–8 cerebral 34 59–62
multidrug-resistant tuberculosis legs 92, 96, 145, 148–50, 153 pituitary failure 50
199, 201 pulmonary 105, 108–9 pituitary-dependent Cushing’s
multiple endocrine neoplasia type oesophageal varices 209–10 syndrome 54–8
1 (MEN-1) syndrome 61 OGTT see oral glucose tolerance plasma glucose 2–5, 34–6, 38,
multiple myeloma 96 test 159
Murphy’s sign 280 opiates 242–3, 246 pleuritic chest pain 183–92
MVP see mitral valve prolapse oral contraceptives 192 pneumonia 141–3
mycetoma 198 oral glucose tolerance test pneumonia see community-
mycobacterium tuberculosis (OGTT) 4 acquired pneumonia;
194, 201 oral hypoglycaemic medication hospital-acquired
myocardial infarction (MI) 9, 10–17 pneumonia
116–17, 124–7, 137–8, orbitopathy 44–8 pneumothorax 189–91
159 osteoarthritis 59, 67–8, 75–6, polyarthritis 64–70
myxoedema 44 77, 150–1 polydipsia 4, 34
osteodystrophy 100 polypharmacy, falls 139–41
osteomalacia 140, 141, 144 polyps, colorectal 293, 294–5,
NASH see non-alcoholic osteoporosis 85, 86–7, 89, 135, 299
steatohapatitis 136, 144 polyuria 4, 34
National Association for Colitis overflow diarrhoea 169–70, popliteal aneurysms 305, 314
and Crohn’s disease 244–5 post-infectious irritable bowel
(NACC) 220 oxygen supplementation 182 syndrome 256–7
Index 335
postoperative care 268 relative risk/absolute risk sexually transmitted infections

postural hypotension, falls concepts 211, 225 257–8
137–8, 139–41 renal disease 91–110 shoulder pain 152, 153
potassium, chronic kidney acute renal failure 103–10 SIADH see syndrome of
disease 102 bone disease 100 inappropriate antidiuretic
PPIs see proton pump inhibitors chronic kidney disease 94–102 hormone secretion
PR see pulmonary regurgitation diabetic nephropathy 6, 8, sigmoidoscopy 208, 221, 224,
pre-renal failure 104, 106–7 20, 22, 25 294–5
prednisolone 82–3 dialysis 25, 102 silent myocardial infarction
pregnancy emergencies 103–10 137–8, 159
anticoagulants 113, 131, 192 gout 73, 74 sinus bradycardia 117
diabetes 8 systemic rheumatological skin changes
gallstones 276 illnesses 81, 82 Addison’s disease 49, 50
hyperthyroidism 48 renal replacement therapy (RRT) Cushing’s disease 54–6
pulmonary embolism 192 25, 102 Graves’ disease 44
suspected appendicitis 288 renin–angiotensin system jaundice 235, 249, 276, 279,
systemic lupus erythematosus inhibitors 30–1 280–2
81, 84 respiratory problems 173–201 rheumatoid arthritis 67
pressure sores 149, 152, 153 chest infection 195 stroke patients 153
proctitis 257–8 dyspnoea 145, 150–1, SLE see systemic lupus
proctoscopy 294 174–82 erythematosus
prophylactic appendectomy 284, haemoptysis 81, 183, 186, sleep apnoea 59, 60
291 193–201 small bowel obstruction (SBO)
prostate problems 93, 99, 169, pleuritic chest pain 183–92 302–3
270, 273, 275 rheumatoid arthritis 67 small vessel complications,
prosthetic heart valves 113, stroke patients 152, 153 diabetes 5–6, 8, 19–26
130, 131 Wegener’s granulomatosis smoking
proteinuria 92, 95, 96, 98 81–2 aortic aneurysm 305, 306
proton pump inhibitors (PPIs) 205, retinopathy 6, 8, 20, 21 breast pain 328
207, 227, 229, 230, 232 rheumatoid arthritis 66–7, 70, 79 bronchial carcinoma 193,
protozoa 207, 208 rheumatoid factor (RF) 64, 66 195–6
proximal myopathy 55 rheumatology 63–89 chronic obstructive pulmonary
PS see pulmonary stenosis back pain 85–9 disease 178–9
psoriatic arthritis 74–5 monoarthritis 71–7 diabetes 6
psychological well-being 151, polyarthritis 64–70 SNB see sentinal node biopsy
152, 154, 163 systemic rheumatological social well-being 152, 154
PTE see pulmonary illnesses 78–84 solitary rectal ulcer syndrome
thromboembolism risk assessment 211, 225, 275, 257–8
pulmonary asbestosis 180–1 291, 310 somatostatin analogues 60, 62
pulmonary embolism (PE) 176, rosiglitazone 11 somatotroph adenoma 59–62
184, 186, 192, 196, 268 RRT see renal replacement speech and language therapy
pulmonary oedema 105, 108–9 therapy 152, 154
pulmonary regurgitation (PR) ruptured aortic aneurysm 308–9 sphincter tone 170
122 spinal stenosis 313
pulmonary stenosis (PS) 122 spirometry 175, 177, 179
pulmonary thromboembolism SAD (syncope, angina, spironolactone 103, 113, 132,
(PTE) 184 dyspnoea) 137 234, 236
purple striae 54–6 saphena varix 271, 272 spontaneous bacterial peritonitis
PVD see peripheral vascular SBO see small bowel obstruction (SBP) 234
disease SBP see spontaneous bacterial statins 29
pyloric stenosis 230–1 peritonitis stenting 304, 308, 310
pyrexia 268 Sengstaken–Blakemore tubes steroids 49–53, 54–8
205, 209 Streptococcus pneumoniae 187–9
sentinel node biopsy (SNB) 327, stress 254, 256
radioiodine 48 328 stress incontinence 166, 170
radiotherapy 58, 298, 299, 326, septic arthritis 72 strokes 146, 151–2, 153–5
327 serum creatinine 92, 93–4, 95, acute confusional states 159
ramipril 113 98 carotid artery dissection
rectal cancer 292, 293, 296–8 sex hormones 59 316–18
rectal ulcers 257–8 sexual abuse 243, 254 incontinence 165, 168–9
336 Index
subacute bowel obstruction TURP see transurethral resection ventricular tachycardia (VT) 115,
222–3 of the prostate 116
sulphonylureas (SUs) 11, 14–15 type 1 diabetes mellitus vertebrae 85, 86–7
superventricular tachycardia diagnosis 7–8, 9, 38–40 vertebrobasilar transient
(SVT) 115 emergencies 34–5, 39–42 ischaemic attack 137–8
SUs see sulphonylureas glucose control 7–8, 17–18 VF see ventricular fibrillation
SVT see superventricular large vessel complications 27, visual disturbance 4, 21,
tachycardia 31–2 139–41, 157
sweating 59, 61 small vessel complications 8, vitamin B12 deficiency 140, 141
Synacthen test 51, 53 19, 22 vitamin D deficiency 144
syncopal events 134, 137 type 2 diabetes mellitus vitamin supplements 321
syndrome of inappropriate diagnosis 5–6, 9 volvulus 302–3
antidiuretic hormone emergencies 34–8 vomiting
secretion (SIADH) 160 glucose control 10–17 appendicitis 284
synovitis 67 large vessel complications bowel obstruction 300, 302
systemic lupus erythematosus 27–31, 33 diabetes 42
(SLE) 79, 80–1, 84, 96 small vessel complications gallstones 276
systemic rheumatological 19–21, 23–6 haematemesis 204, 205,
illnesses 78–84 209–10, 233, 237–8
systemic vasculitis 79, 81–3, 98 inflammatory bowel disease
ulceration 145, 148–50, 153, 219, 222
311, 313, 319–21 obstructed hernia 273–4
TB see tuberculosis ulcerative colitis 204, 207–9, pancreatitis 212, 215
TC see total cholesterol 211, 219, 221–2, 225 peptic ulcer disease 230
temperature, postoperative 268 ultrasonography 277, 288, 289 renal disease 100, 103, 106
temporal arteritis 79, 82–3 universal ALS algorithm 118 VSD see ventricular septal defect
tenesmus 257–8, 293, 297 urge incontinence 166 VT see ventricular tachycardia
therapy compliance 199–200, urinary problems
264–5 benign prostatic hypertrophy
thiamine 210 270, 273, 275 warfarin 131, 151, 206, 207
thiazolidinediones 13, 15, 17 incontinence 148, 151, 153, Wegener’s granulomatosis 79,
thin basement membrane 165–72 81–2, 98
disease 97 obstructions 99, 104, 142, 169 weight gain
thirst 212, 214 urinary tract infections (UTIs) 22, ascites 235
thromboembolism 184, 186, 192 159, 163–4, 166, 268 Cushing’s disease 54–6, 58
thrombophilia 186, 192 uterine prolapse 165–6, 170–1 diabetes 4, 11–12, 34
thrombosis 268, 314–15 irritable bowel syndrome 255
thyroid dysfunction 44–8, 123, weight loss
161, 263 valvular heart disease 120–2, Addison’s disease 49–51
TIA see transient ischaemic 129–30, 131 coeliac disease 260, 263
attack varices 209–10, 237–8 diabetes 4, 13, 34
torsades de pointes 116 varicose veins 320 dyspnoea 174, 180
total cholesterol (TC) 29 vascular disease giardiasis 256–7
TR see tricuspid regurgitation see also cardiovascular hyperthyroidism 44–5
trans-sphenoidal adenoma disease; strokes irritable bowel syndrome 255
debulking 60, 62 aortic aneurysm 304–10 malignancy 195, 281, 297,
trans-sphenoidal carotid 316–18 301
microadenomectomy 57, 62 cerebrovascular 28, 317 pancreatitis 214, 218
transient ischaemic attack (TIA) diabetic large vessel 27–33 peptic ulcer disease 226, 230
137–8 diabetic small vessel 19–26 rheumatoid arthritis 67
transplantation 102, 239 peripheral 28, 311–15 Weil’s disease 249, 250
transurethral resection of the vasculitides 79, 81–3 Wernicke’s encephalopathy 161,
prostate (TURP) 275 venous ulcers 319–21 210
tricuspid regurgitation (TR) 122 vasovagal episodes 137 whiplash injuries 316–18
tricuspid stenosis (TS) 121 venous ulcers 319–21 wide local excision (WLE) 326,
tuberculosis (TB) 51, 187–8, ventricular fibrillation (VF) 116, 327, 328
194, 198–200, 201 126
tubular necrosis 104 ventricular premature beats 116
tumours see adenomas; ventricular septal defect (VSD) X-linked adrenoleukodystrophy
carcinomas 122 51

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What is the book about?

What is the book about?

What topics are covered in the book?

What topics are covered in the book?

Core

Core Clinical Cases in Basic Biomedical Science

Core Clinical Cases in Medical and Surgical Specialties

Core Clinical Cases in Medicine and Surgery

Core Clinical Cases in Obstetrics & Gynaecology 2nd Edition

Core Clinical Cases in Paediatrics

Core Clinical Cases in Psychiatry

Core Clinical Cases series edited by

Janesh K. Gupta MSc MD FRCOG

Distributed in the United States of America by

© 2006 Steve Bain and Janesh K. Gupta

British Library Cataloguing in Publication Data

Library of Congress Cataloging-in-Publication Data

ISBN-10: 0 340 81670 8

Commissioning Editor: Georgina Bentliff

Typeset in 9 on 12 pt Frutiger Light Condensed by Phoenix Photosetting, Chatham, Kent

Chapter 4 Renal medicine 91

Chapter 5 Cardiology 111

Chapter 6 Care of elderly people 133

Chapter 7 Respiratory medicine 173

Chapter 8 Gastroenterology 203

Chapter 9 General surgery 267

C. S. Probert MD ILTM FRCP, Consultant and Reader in Gastroenterology, University of Bristol,

Neeraj Prasad MD FRCP, Consultant Cardiologist, Hereford County Hospital, Hereford, UK

Neil C. Thomson MBChB MD FRCP, Professor of Respiratory Medicine, University of Glasgow,

Nevianna Tomson MBChB MRCP, Specialist Registrar in Dermatology, Addenbrookes’ Hospital,

In undergraduate medical education there is a trend towards the development of ‘core’

Why a problem-solving approach?

How will this book inspire problem-solving traits?

In clinical practice, any therapeutic strategy has to be conveyed to patients in a manner

CTPA CT pulmonary angiogram FFP fresh frozen plasma

HRCT high-resolution computed MRI magnetic resonance imaging

RRT renal replacement therapy TSH thyroid-stimulating hormone

rtPA recombinant tissue plasminogen TEDS thromboembolic deterrent

RV right ventricular TTP thrombotic thrombocytopenic

? Questions for each of the clinical case scenarios given

CASE 1.3 – A 21-year-old woman with a random ﬁnger-prick glucose of

OSCE Counselling Cases

random plasma glucose ≥ 11.1 mmol/L

fasting plasma glucose ≥ 7.0 mmol/L

Q2: What investigations would you request to conﬁrm a diagnosis?

Q3: What examination would you perform?

Q4: What would be the initial management?

Q5: What are the long-term sequelae?

Q2: What investigations would you request to conﬁrm a diagnosis?

Q3: What examination would you perform?

Q4: What would be the initial management?

Q5: What are the long-term sequelae?

Other cardiovascular risk factors include:

Smoking: advise complete cessation.

CASE 1.3 – A 21-year-old woman with a random ﬁnger-prick glucose of

Q2: What investigations would you request to conﬁrm a diagnosis?

No laboratory conﬁrmation is necessary.

Q3: What examination would you perform?

Q4: What would be the initial management?

Q5: What are the long-term sequelae?