Examination Medicine: A Guide to Physician Training, 7th Edition

CHAPTER 14. Think like a physician, think like an examiner – an approach with long case examples

I should have liked to be asked to say what I knew. They always tried to ask what I did not know. When I would have willingly displayed my knowledge, they sought to expose my ignorance. This sort of treatment had only one result: I did not do well in examinations.

Winston Churchill

The cases set out below are examples of typical and realistic long case patients. We have framed the case outlines from an examination perspective, including typical points likely to be raised in the discussion and clinical traps candidates may fall into. Think about how you would cope with them and what sorts of questions you might predict.

Only the most important parts of the history are summarised, as might be obtained by the examiners (not how you would present the case).

CASE 1

Mrs AB 3 is an outpatient and former hospital nurse. She has been unable to work for some years because of her illness.

In 2007, 2 weeks after the birth of her third child, she developed joint pains and swelling of the hands and feet. She had not had any rashes.

Investigations at the time led to a diagnosis of SLE.

She was treated with prednisone doses varying from 10 to 30 mg.

Steroid sparing agents such as azathioprine and mycophenalate were tried, but led to side-effects, but she is not sure what these were. Methotrexate caused febrile neutropenia. Diclofenac and hydroxychloroquine were not very effective.

In 2008 she had an episode of pleuritic chest pain, was diagnosed with pericarditis, admitted to hospital and treated with prednisone, starting with 40 mg. Her symptoms resolved over a few days.

In 2009 she had sudden loss of vision in one eye and retinal vein thrombosis was found. She was then diagnosed with anti-phospholipid syndrome and began treatment with warfarin.

In 2009–10 she had recurrent nocardia infections – skin, muscles (calf) and brain. There was no neurological deficit, but she had severe headache. This was treated successfully with cotrimoxazole.

In 2010 she developed left-sided paraesthesiae and vertigo. A TIA was diagnosed. A CT of the brain and carotid Dopplers were normal. Aspirin was added to her treatment.

In 2011 a pruritic rash developed on her legs and cotrimoxazole was stopped.

Her steroid use was associated with a number of problems: weight gain from 65 to 95 kgs; her BMI is now 35; she developed gestational diabetes needing insulin, but is now taking metformin. She is unsure of her current BSL; she checks it every 4 days or so. She has not had a hypoglycaemic episode; she doesn’t know her HbA1c.

She smokes 15/day and her husband smokes.

She looks after her 3 children at home; once a week she rides a bike with them, but her joints become very sore afterwards.

Joint symptoms and muscle weakness limit household work, e.g. putting out washing. Her husband works 6 × 12-hour days. She gets some support from her family at home.

She has an IUD for contraception and PV bleeding has improved with a progesterone device.

There have been no other rashes.

She has no kidney disease as far as she knows. There has not been a problem with hypertension.

Her last INR was 1.4. She has monthly tests.

Her eyes are reviewed regularly.

She is keen to work again as a nurse or clerk, but has been told this is not possible by her doctors.

She sees her main problem as her inability to work and exercise.

Examination

On the day of the exam the important examination findings were:

1. She was Cushingoid.

2. There was swelling without deformity involving the hands and wrists.

3. She had a healing rash on the legs (likely cotrimoxazole associated).

4. Her BP was 130/90 mmHg.

5. There was mild prox muscle weakness – she could stand with effort from chair without using her arms.

6. The left fundus was pale with 6/12 vision.

Discussion

First examiner

1. SLE

a. Serology and diagnosis and role of follow-up blood tests

b. Management of joint symptoms: drugs, exercise, physiotherapy

c. Steroids and doses

d. Future complications of SLE; especially kidneys

e. Nocardia prophylaxis

2. Diabetes:

a. routine discussion: how diagnosed, family history

b. vascular risk

c. renal risk

d. role of ACEI

e. BSL measurements

f. weight loss

g. smoking cessation strategies

h. patient’s understanding of prognosis.

3. Warfarin – INR monitoring and use of aspirin for anti-phospholipid syndrome.

Second examiner

1. Contraception issues.

2. Prognosis and psychological state, patient’s view of her main problem.

COMMENTS

1. Management problems of SLE and its treatment.

2. Complicated history needs to be presented succinctly and logically – probably best given chronologically.

3. Some common management area for discussion, e.g. diabetes. This needs to be done smoothly – should be straightforward so a high standard would be expected.

4. Indication for and management of anticoagulation and management of initial or recurrent pericarditis are very likely areas for discussion depending on time available. Much detail about patient’s management and understanding of warfarin will be expected. You would need to know where and how often INR readings are taken, how result is communicated to patient and who makes dose adjustments. What happened after the last reading of 1.4?

5. Current management of stroke/TIA could be asked about and use of warfarin and aspirin.

6. Plenty of scope for effect of illness on family, income, work, self-esteem and so on.

7. Need to be able show how you would discuss the prognosis with the patient.

CASE 2

Mr BC is a 68-year-old accountant in full-time work. He has come in for the exam from home. He has a younger wife and his youngest child is only 5.

He has had a recent admission to hospital with a chest infection and was diagnosed with COPD.

In 1996 he was diagnosed with chronic kidney disease. He had a biopsy but the diagnosis was unclear, at least to him. He was treated with haemodialysis for 18 months. He still has a functioning fistula in the left arm.

In 1997 he had a cadaveric transplant. Immunosuppression was with prednisone and azathioprine.

In 1998 he developed gout and was treated with colchicine and allopurinol. There has been no recurrence.

Azathioprine led to bone marrow suppression, admission to hospital and he required blood transfusion. Azathioprine was stopped and cyclosporin started.

His current creatinine is 250. He doesn’t know his eGFR, but says his creatinine has been stable for many years, but had increased to 270 umol/L during his recent admission.

His cyclosporin dose was reduced last year and mycophenolate added to his treatment.

He is not worried about his current renal function.

In 2007 he had left and then right hip replacements. He thinks the left was because of avascular necrosis and the right was because of osteoarthritis. He is not aware of having had any bone density assessments.

His recent admission was with dyspnoea and productive cough – antibiotics and steroids were used to treat this, but have now been stopped.

COPD was diagnosed but his spirometry measurements were not abnormal as far as he knows. He smoked until 5 years ago – 25 packet years altogether.

His cough is still productive. He can walk 200 m on the flat, he plays golf with a cart.

He is being treated with symbicort II bd and salbutamol 2 puffs prn.

Obstructive sleep apnoea (OSA) was diagnosed in 2007. He snores and has mild day-time sleepiness but never when driving. His sleep study was positive. He has been unable to tolerate a mask.

He has been overweight for many years and is currently 140 kg for 2 m of height. He has been unable to lose weight despite insight into his problem.

He has a long history of hypertension, which has been difficult to control since he developed kidney disease. His current treatment for this includes: diltiazem 180 daily, candesartan 16 daily, prazosin 5mg bd and hydralazine 50/mg bd.

He had angioedema with an ACEI and his ARB was initiated in hospital.

In 2010 he had symptomatic AF requiring two cardioversions. He takes amiodarone 200 bd for this and has had no symptomatic recurrences. He is anticoagulated with warfarin. His INR target is 2–3 and he is having weekly blood tests. His INR was 5.4 during admission when on antibiotics. He has had no bleeding problems.

He has peripheral oedema much worse with diltiazem 360 mg. He has never used support stockings, but takes frusemide 80 mg daily. An episode of cellulitis in the legs occurred 2 years ago and required treatment with IV antibiotics.

He still works and supports his family (sedentary job, good employer), but he is not sure for how much longer he will be able to continue. He feels his breathlessness is his worst problem.

Examination

The examination revealed:

1. Obesity.

2. BP 120/80 mmHg, Pulse 80 regular.

3. Not dyspnoeic at rest, loose cough.

4. Not clubbed.

5. Widespread polyphonic wheezes and coarse inspiratory crackles.

6. Reduced chest expansion.

7. Soft systolic ejection murmur, apex beat not palpable.

8. Peripheral oedema moderately severe and venous staining.

9. Transplant palpable in abdomen, left arm fistulae working.

Test results available to examiners:

1. CXR increased lung markings, thickened bronchial walls, overinflated chest.

2. ECG left bundle branch block, sinus rhythm.

3. Spirometry FEV1/VC 71% little reversibility.

4. Echo severe LV, dilated left atrium, systolic function preserved.

Discussion

First examiner

1.  

a. What does patient see as his main problem? Does COPD explain all the symptoms and signs?

b. What other possibilities, e.g. bronchiectasis, pneumocystis, bronchopulmonary aspergillosis?

c. How to investigate and manage?

2.  

a. Current renal function satisfactory or a problem?

b. What measures to investigate and treat? E.g. BP, chronic rejection, cyclosporin?

c. Surveillance of current anti-rejection Rx: full blood count, skin, blood levels, indications for kidney biopsy?

3. AF management, amiodarone toxicity and surveillance, warfarin management.

4. Peripheral oedema significance and management – calcium antagonists, venous problems, right heart failure – any signs of this?

Second examiner

1. Obstructive sleep apnoea management – what else to do?

2. Chronic illness, work, money, etc.

3. Obesity – what approach? (if time)

COMMENTS

A long case with a number of active problems.

1. Recent lung disease perhaps not explained by COPD.

2. Renal function possibly deteriorating despite patient’s claim of stable creatinine.

3. Opportunity to discuss management of surveillance of anti-rejection Rx.

4. Management of AF and warfarin and amiodarone.

5. Approach to peripheral oedema not always or even usually heart failure but possibility of right heart failure and pulmonary hypertension.

6. OSA and obesity.

The examiners would be keen for a differential diagnosis of his dyspnoea and lung disease. You would want to talk about transplant surveillance and management. There would be time for both.

CASE 3

Mr WP 64 is a wheat farmer who is currently in hospital 100 km away from his home and farm.

In 2008 he discovered a painless testicular mass. There were no sweats or fevers. He underwent a single orchidectomy. He was unable to remember a preceding biopsy. Lymphoma was diagnosed.

He was treated with 8 cycles of R-CHOP treatment delayed by drug side-effects (fever, oedema), but completed in 8 months and followed by maintenance rituximab.

In 2011 he relapsed. He developed back pain and left leg weakness. There were no bowel or bladder symptoms. He was admitted to hospital for 5 months and unable to walk. There was numbness of the left leg and a necrotic ulcer developed on the heel. There was little improvement in power while he was in hospital.

He then had an episode of diplopia and ptosis without associated headache.

An MRI of the brain was performed. He was unsure of the result. During the same admission he had an episode of chest pain and dyspnoea. A CTPA showed pulmonary embolism.

He was treated with intravenous and intrathecal methotrexate and anticoagulated with warfarin. An episode of pleuritic chest pain was diagnosed as pericarditis. He is not sure how this was treated.

He is currently awaiting autologous bone marrow transplant, having had stem cell harvesting.

He has lost 15 kg during this illness.

In the past he has had a CVA in 2007. This was treated with clopidogrel.

A transoesophageal echo showed a patent foramen ovale. He had a long history of hypertension and hyperlipidaemia. He was never a smoker.

His main worries about his health are about his prospects of recovery and return to his family and the farm, which is currently being managed with difficulty by his son.

Examination

1. Left foot drop with S1 and L5 loss of sensation.

2. Absent reflexes in the left leg.

3. Moderate weakness of knee extension and flexion mild weakness at hip.

4. Right leg normal power and reflexes.

5. Absent right testis.

6. Eye movements normal.

Investigations available to the examiners

1. Histology – Large B cell lymphoma.

2. MRI brain thickening of right 3rd nerve within the prepontine cistern.

3. MRI foot showed osteomyelitis.

4. CTPA showed a pulmonary embolus in the lateral segment of the right middle lobe.

5. MRI lumbar spine retroperitoneal lymphadenopathy on the left side of the pelvis and involvement from L4 to the sacral nerves extending to the cauda equina nerve roots.

Discussion

First examiner

1. Management of lymphoma and BM transplant:

a. a common transplant problem, immunosuppression surveillance

b. lymphoma staging – presentation with non-lymph node involvement, no B symptoms implications for prognosis

c. common side-effects of CHOP and rituximab

  Appropriate tests (as above) and their interpretation.

2. Management of osteomyelitis.

3. Management of leg weakness – including rehabilitation.

4. Loss of independence and prognosis.

Second examiner

1. Anticoagulation – management of TIA and PFO, use of clopidogrel vs aspirin.

2. Ability to work, run farm, etc. How has he coped with 5 months in hospital, far from family?

COMMENTS

A complicated case involving:

1. Diagnosis of lymphoma – discussion about staging, etc.

2. Complications of treatment, first of drugs and then theoretically about complications of bone marrow transplant.

3. Disease recurrence with a variety of neurological problems and problems of immobility – necrotic ulcer, psychological.

4. Significant examination findings.

5. Need for anti-coagulation; opportunity to discuss warfarin management.

6. Investigation of possible cerebral ischaemic episode. Significance of PFO.

7. Patient’s concerns about his prognosis. Loss of income, separation from family, long period in hospital – all possible areas for discussion.

The examiners have plenty to choose from and are likely to want to discuss some problems in detail and to ensure the candidate has thought about the others by asking a few questions on each.

CASE 4

Mrs AP is a 72-year-old retired nurse who has come in for the exams.

She has a long history of hypertension, which has recently been difficult to control. A CT of the renal arteries showed ‘thickening’.

She smoked for 18 years until 10 years ago. She has had lower back pain for 10 years, not relieved following a laminectomy. Spinal canal stenosis was diagnosed 4 years ago.

She has had a gain in weight over the last 5 years from 88 to 107 kg. Her BMI is 40.

A thyroidectomy was performed in 2008 following a biopsy which showed atypical cells. The tumour, however, was benign.

She is breathless on mild exertion, but not at rest.

She had a right hip replacement in 2000.

In 2010 she had a left hip replacement. She became very dyspnoeic 5 weeks later, with investigations for a DVT. There were multiple pulmonary emboli, but no DVT was found. She was treated with enoxaparin and then warfarin for 10 months.

Currently she can walk 30 metres on the flat. She is limited by dyspnoea and knee pain.

She has been diagnosed with asthma and an allergy to cats and dogs. She has 3 cats at home.

She suffered from childhood chest infections and sinusitis but no ear infections. She coughs up little phlegm and has never had an admission to hospital with asthma or required steroid treatment.

In 1999 hypogammaglobulinaemia was diagnosed. She was given vaccinations for influenza, whooping cough, pneumonia (possibly pneumococcus and Haemophilus influenzae) and hepatitis.

She now receives monthly gammaglobulin injections. These were given IM for 5 years, then IV. She feels she is much improved and requires only one or two courses of antibiotics per year now.

She is currently taking atenolol 50 mg a day for hypertension and detected ventricular bigeminy (asymptomatic). She had had problems with previously prescribed ACE inhibitors and AR blockers, but can’t remember what they were.

She is unable to drive and only goes out with a frame. Her husband does the shopping and housework.

Her main concern about her health was her back pain. She was not especially worried about her immobility or her weight.

Examination

1. Obese.

2. BP 150/80 mmHg.

3. Able to walk with great difficulty, but not apparently concerned.

4. Chest clear.

5. FET normal −5s.

Discussion

First examiner

1. History of childhood infections and asthma: Was this typical of hypogammaglobulinaemia? Did she have time off school? Admissions to hospital? Inability to play sport, etc?

2. Dyspnoea – current causes: Obesity? Asthma? PE or something else? How to investigate?

3. Back pain – has this been nocturnal? Is its current treatment satisfactory? This is her main worry.

4. Obesity – is she serious about weight loss? What is her attitude to illness? Is there some secondary gain?

5. Asthma – she has pets at home that she is said to be allergic to. How severe is it? Is current Rx satisfactory?

6. Immobility – what might be done?

Second examiner

1. What risks would further surgery involve? How would you advise her anaesthetist?

2. Hypertension – is it well controlled? Is there a need to investigate and consider renal artery angioplasty? Discuss use of beta blocker.

COMMENTS

1. Problem of a patient enthusiastic about her illnesses.

2. Sometimes difficult to get to the point during history-taking, but of course a problem for examiners as well.

3. Any illness that begins in childhood requires questions about its effect on education – time off school, playing of sport, socialising with other children and effect on final level of education.

4. Discussion about treatment of problems that seem severe, e.g. immobility, but do not really seem to worry the patient.

5. Some more straightforward medical problems, e.g. hypertension, possible renal artery stenosis, use of beta blockers for an asthmatic.

This case has an interesting mix of significant medical, but also of social and perhaps psychiatric problems. A good candidate needs a sensible and realistic approach to these probably insoluble aspects of the case.

CASE 5

Mrs CE is a 73-year-old outpatient with chronic renal failure and on haemodialysis.

The aetiology of her chronic kidney disease was analgesic nephropathy; she used Vincent’s Powders at the rate of 36 a day for 25 years and stopped 30 years ago.

She has now been dialysing for 2 years. She has 5 hours 3 times a week. Her right arm fistula works well. She has had recurrent renal ‘stones’.

She doesn’t know her dry weight and is unsure about fluid, salt or dietary restrictions. She remembers having had some parathyroid problems while on tablets in 2009. Her calcium levels were too low and the tablets were stopped.

In 2007 her renal failure was precipitated after an episode of pancreatitis requiring ICU admission. She remembers severe abdominal pain, but little else of this illness. The pancreatitis has meant she is not suitable for peritoneal dialysis.

She passes no urine.

In 2004 she swallowed a fish bone and developed peritonitis and required emergency surgery.

In the past she drank 6–8 whiskies a day (more when friends visited) for 10 years. She is now a non-drinker.

She thinks her liver is normal now. There have been no problems with it or with exocrine pancreatic function.

Hypertension was diagnosed after this illness and is being treated with metoprolol 50 mg daily.

There is some exertional dyspnoea but no orthopnoea. Her back limits her more than shortness of breath. This has been present since she was assaulted by her first husband over many years.

She needs a knee replacement. She has had both her hips and the left knee replaced. Three lots of back surgery have been performed following her injuries. A new left knee replacement has been recommended after she fell on her knee a few months ago.

She has no history of ischaemic heart disease. She does not know if her cholesterol level is elevated. She smoked for 20 years until 10 years ago.

There is a history of gout many years ago.

Her medications include:

• analgesics for her back (she is not sure what these are at the moment)

• arensep monthly (doesn’t know current haemoglobin)

First marriage at 16. Very difficult life with first husband.

She cannot drive. Her husband brings her to dialysis 40 mins from home and does all the housework, shopping and cooking. He is very different from her first husband whom she divorced 29 years ago. She remarried 5 years ago. She has two children, one of whom lives locally.

Gall stones have been found and an ERCP recommended. Gall stones were not found at the time of her pancreatitis.

She is very happy in her second marriage. Her main concern about her health is her immobility and constant back pain.

Examination

1. BMI 24.

2. Working fistula.

2. Blood pressure 120/80 mmHg, pulse 70/min. 1/6 systolic ejection murmur.

4. Scars over cervical and lumbar spine.

5. Abdominal examination normal.

6. Peripheral pulses normal.

7. Reflexes normal.

8. Power limited by knee pain.

Discussion

First examiner

1. Discussion about details of illness that led to dialysis and analgesic nephropathy (now rare).

2. Dialysis problems: diet, calcium levels, drugs, cardiovascular protection.

3. Patient’s understanding of her illness.

4. Back pain management (one of her main concerns).

5. Is she a candidate for a transplant? Screening for transitional cell carcinoma.

Second examiner

6. Fitness for knee surgery.

7. Significance of murmur.

COMMENTS

1. This case involves the usual discussion about CKD and dialysis: cause of renal failure, choice of type of dialysis, patient’s understanding of illness – dry weight, diet, haemoglobin, etc.

2. Analgesic nephropathy is now a rare cause of CKD, but candidates need to know something about it – including risk of transitional cell carcinoma.

3. This woman had a very difficult life for many years with her first husband and now copes with her chronic illness cheerfully – some details about her domestic problems and their effect on her current state of mind are important.

4. Common further questions would involve asking about your management of her back pain and discussion of her suitability for knee surgery and transplant. These may not have clear-cut answers, but a sensible approach would be expected.

CASE 6

Mr AH is a 76-year-old retired stockbroker. He is an outpatient.

Problem list provided to the examiners

1. Type 2 diabetes.

2. Asthma.

3. Hypertension.

4. Muscle cramps secondary to statin use.

5. Carcinoma of the prostate.

6. Carcinoma of the colon.

7. Social aspects.

8. Knee replacements.

Mr AH was due to have CT scans of his chest abdomen and pelvis as follow-up of his two malignancies and felt anxious about the results of these tests.

Carcinoma of the prostate was diagnosed in 2006 after a screening PSA test. Radical prostatectomy and external radiotherapy was the management.

He had a period of urinary incontinence, which has now resolved.

There was minor radiation proctitis.

Carcinoma of the colon was diagnosed in 2009 after a positive screening faecal occult blood test – anterior resection but no colostomy.

Several adjacent lymph nodes were involved.

His postoperative course was complicated by a period of bowel obstruction and he required parenteral feeding for 10 days.

He had a course of chemotherapy including, he thought, 5 FU and a platinum-based drug. The main complications were nausea and painless peripheral neuropathy. The neuropathy has improved slightly if anything.

Follow-up colonoscopies and CT scans have been normal so far.

There have been no bowel symptoms apart from some intestinal hurry.

Type 2 diabetes was diagnosed in 2006. It has only ever been treated with diet. He has lost no weight since the diagnosis and is currently 100 kg (BMI 30). HbA1C recently was 6.1. He has had no identified complications of diabetes. He checks his BSL every few days.

He has had a recent episode of cough wheeze and fever.

He reports recurrent childhood asthma, but no problems with missing school and no admissions to hospital.

His chest symptoms occur almost every winter and are debilitating; he produces large volumes of discoloured sputum.

He has been given five courses of antibiotics this year.

He thinks one set of sputum cultures has been performed, but doesn’t know the result.

There have been no chest investigations for years.

Last year he had a nasal polyp removed.

Has frequent problems with a blocked nose and symptoms of sinusitis which usually precede his chest symptoms; sometimes he uses intranasal steroids.

He has often treated with a course of prednisone for 10 days by his local doctor for these illnesses.

He uses regular seretide 2 puffs mane and salbutamol as required.

He has been treated for hypertension for 6 years with candesartan/hydrochlorothiazide.

He has been told he has a heart murmur which needs review in a few years.

He associated the use of two different statins with muscle pains in the legs and has stopped them; he is unsure of his untreated cholesterol level.

He is moderately active; plays golf using a cart and walks 3 km 5 days a week. He is mostly limited by joint problems – two previous knee replacements and chronic back pain and two previous laminectomies, but also by dyspnoea and wheeze.

His wife, who is affected by dementia, has been admitted in the last few weeks to a nursing home which is half an hour’s drive away. He drives to visit her 6 days a week. He lives with his 48-year-old son who works but is mildly mentally retarded. He has three other children whom he sees often.

He smoked until 25 years and has a 25-packet-year history of smoking. He drinks 4 or 5 glasses of wine a day.

When asked what troubled him most he described his worry about his forthcoming screening tests and the limitations caused by his frequent respiratory symptoms.

Examination

1. Obesity.

2. Abdominal and back and knee scars.

3. BP 135/70 mmHg pulse 75/minute and regular.

4. There were occasional expiratory wheezes, his cough was dry.

5. He had signs of mild aortic regurgitation and stenosis.

6. Peripheral neuropathy in stocking distribution – hands unaffected. Reflexes absent distally and proprioception and vibration sense reduced.

Discussion

First examiner

1. Diagnosis of respiratory symptoms: asthma vs COPD. Possibility of bronchiectasis. What investigations are indicated, e.g. CXR, HRCT of the chest, sputum culture (possibility of unusual organisms, e.g. atypical mycobacteria, pseudomonas)? Investigation of sinusitis because this seemed to precipitate attacks. IgE for bronchopulmonary aspergillosis. Lifelong problem of recurrent infections – consider immunodeficiency and investigate. Consider aspirin sensitivity, however, he takes regular aspirin without difficulty.

2. Management of respiratory problems: once daily seretide – is this appropriate? Is intermittent steroid treatment appropriate? Management of sinusitis, e.g. regular inhaled nasal steroids. Should he have antibiotics or steroids at home for use at onset of symptoms? Would postural drainage, a flutter valve or physiotherapy be helpful for his productive cough?

3. Is candidate happy with the current management of follow-up of the two malignancies? What to do if PSA up again? Is it worth checking the CEA?

4. Strategy for treating lipids in view of his intolerance to statins.

Second examiner

1. How is he managing at home? Does he have problems with depression?

Does he drink too much? What would you say to him about this?

2. Management of valvular disease. Which is more significant lesion?

COMMENTS

1. This man appeared well and might have been included in the exam because of his two malignancies, but the more significant unresolved problem was his recurrent productive cough. This is an excellent topic for discussion and it is likely the examiners would be keen to pursue this problem. You would also want to talk about diabetes management and cancer surveillance.

CASE 7

Mr RD is a 66-year-old retired public servant.

Problem list provided to examiners

1. Antibody deficiency.

2. Chronic wound right thigh, previous necrotising fasciitis.

3. Type 2 diabetes.

4. Ischaemic heart disease.

5. Hypertension.

6. Hypercholesterolaemia.

7. Obstructive sleep apnoea.

8. Gastro-oesophageal reflux.

9. Hypothyroidism.

10. Opioid dependence.

11. Subacute bowel obstruction.

12. Inflammatory bowel disease, procto-colectomy 1998.

His gut problems began in 1996 with bloody diarrhoea and a diagnosis of inflammatory bowel disease.

Biopsies were more suggestive of Crohn’s colitis and he was treated for a few years with steroids and azathioprine. He was intolerant of sulphasalazine.

Biological agents were not available at that time and poor control of his symptoms led to a proctocolectomy and the need for an ileostomy drainage bag. He had further surgery with relocation of his stoma in 2006 because of a parastomal infection.

There were recurrent admissions to hospital with subacute bowel obstruction. Opioid dependency developed at this stage.

In 2009 he had further surgery to relieve adhesions, which was largely successful.

His stoma works continuously and he empties it three times a day.

He does not know how much small bowel was resected.

His appetite has been poor since the wound problems and he has lost 20 kg. He takes Ensure supplements.

Two years ago he had surgical removal of two skin lesions on his right thigh. The wound broke down and numerous further operations were performed. The wound was complicated by necrotising fasciitis. Various organisms, including e.coli spp, were cultured. He has a photographic record of the wound, which he was keen to show. An immunoglobulin deficiency was diagnosed after investigations for failure of his wound to heal. He has intermittent human IV immunoglobin infusions.

He had two myocardial infarctions in 1997 and then a stent to the right coronary artery in 1998. He describes recurrent episodes of what he called ‘unstable angina’ requiring admission to hospital and narcotic analgesics in 2010, but an angiogram showed his stent was patent and there was no obstructive disease. His chest pain was atypical and not associated with ECG changes.

There was a history of hyperlipidaemia and hypertension, currently treated with artorvastatin 10 mg and he is not currently on anti-hypertensives. He has not smoked for 18 years.

He takes clopidogrel rather than aspirin because of gastro-intestinal side-effects associated with aspirin.

Type 2 diabetes was diagnosed in 1999. He measures his BSL ‘randomly’; results are between 4.5 and 9 mmol/L and he does not know his HbA1C.

He has regular eye checks and has no nerve problems.

Metformin was associated with diarrhoea and he takes glimepiride. This dose has been reduced because of episodes of hypoglycaemia. He believes his renal function is normal.

He has had a diagnosis of obstructive sleep apnoea; this appears to be mild and is not being treated.

He lives at home with his wife who is well. His son died 3 years ago from complications of type 1 diabetes. He has no particular financial worries. He drives and is moderately physically active. He uses morphine on a daily basis for thigh pain.

Examination

1. He appeared well nourished.

2. Blood pressure 130/80 mmHg, pulse 65/minute and regular. No signs of heart failure.

3. The thigh wound was almost healed, except for small area at the lower margin.

4. The stoma appeared satisfactory and the abdominal examination was otherwise normal.

5. There was no peripheral neuropathy.

Discussion

First examiner

1. History and management of IBD, including malabsorption and nutrition.

2. Ischaemic heart disease.

3. Candidates could be asked to speculate on the original cause of the thigh wound. Remember pyoderma gangrenosum and necrobiosis diabeticorum. Discussion about the slow healing should consider his antibody deficiencies as well as his Crohn’s disease. The recurrent infection with bowel organisms and curious photographic record of the wound might make you think about a factitious cause.

4. While discussing the management of his IBD, also consider investigation of possible malabsorption, e.g. vitamin B12 deficiency and tests for this, e.g. blood count, serum albumin, folate and B12levels, vitamin D.

Second examiner

1. Possible ischaemic heart disease would lead to a standard spiel about risk factor control. But don’t take the patient’s assertion that he had experienced recent acute coronary syndromes at face value. Make sure you ask about the characteristics of the symptoms. Think, is the diagnosis was incompatible with the angiography findings? What about the influence of the opioid dependence on the symptoms?

2. You may be keen to wheel out your usual diabetes presentation, but you may not be allowed to by the examiners.

3. There may only be time for a brief discussion of the opioid problem with the usual discussion about referral to the pain management clinic.

COMMENTS

This complicated patient could provide good candidates with an opportunity to look beyond what they were told to achieve a high mark. Never blindly believe the history – look for evidence to support your diagnoses, and always consider a different diagnosis in every long case (and in clinical practice).