Clinical Cases

A Step-by-Step Approach

Andrew Solomon, Julia Anstey, Liora Wittner

• Editore: CRC Press
• Anno: 2021
• ISBN:
  9781351257701
• Edizione: 1
• Argomento: Medicine
• Categoria: Medical Theory, Practice & Reference

It is vitally important for medical students and junior doctors to grasp an understanding of 'real-life medicine'. This innovative book of cases shows how a particular presentation may progress, and the different complications that may arise and emerge over time, which may be missed by the 'snapshot in time' approach taken by many problem-based volumes. The content reflects the average length of stay for a patient in hospital, in which their situation can change in a multitude of ways, and the management of chronic conditions may also need to be adapted as complications arise.

• Demonstrates the real bedside experiences that medical students can expect, in whichever simple or complex way that they may present

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• Cases selected from a range of sub-specialties for comprehensive coverage across the curriculum

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• Illustrates the complicated, progressive problems that will be seen while practicing as a doctor with detailed diagrams and diagnostic imagery to aid understanding

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• Shows, with timepoints, how differential diagnoses may change as more information becomes available and new symptoms arise

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• Describes a typical initial hospital stay, and subsequent presentations to the general practitioner and hospital readmission

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The Authors

Andrew Solomon, BM BCH MA(Hons) DM FRCP, is a Consultant Physician, East and North Hertfordshire NHS Trust, Stevenage, UK.

Julia Anstey, BSc (Hons) MBBS, is a Foundation Doctor, Somerset NHS Foundation Trust, Taunton, UK.

Liora Wittner, MBBS BSc, is a Resident in Internal Medicine, Shamir Medical Centre, Be'er Ya'akov, Israel.

With contributions from

Priti Dutta, MBBS BSc FRCR, Consultant Radiologist, Royal Free London NHS Foundation Trust, London, UK.

Case 1

Timepoint

1

Mr Marsh, a 35-year-old teacher, has presented to the emergency department with a 2-day history of feeling weak in his legs and increasing difficulty walking. He is normally very active, and plays football in his spare time, however, he is now finding it difficult to stand for more than a few minutes. Over the last day, he has started to get pins and needles in his arms and feet and has pain in the rear of his neck. His bowels are functioning normally, but he has found that he is urinating more frequently than usual.

Prior to this, Mr Marsh has been generally well, apart from having ‘food poisoning’ 3 weeks ago. He has no significant past medical history, is currently on no medications and has no drug allergies. He does not smoke and drinks alcohol socially twice a week.

His observations are:

• Respiratory rate: 14/min
• Oxygen saturations: 99% on room air
• Temperature: 36.8°C
• Blood pressure: 112/74 mmHg
• Heart rate: 72 bpm

On examination, Mr Marsh looks generally well. Cardiorespiratory and abdominal examinations are normal. A neurological examination of the upper limbs revealed asymmetric and variable power in the biceps, triceps and other muscle groups with altered sensation in an indistinct distribution across both arms. Examination of the lower limbs revealed increased tone, generalized reduced power (MRC 4+) amongst all muscle groups, normal to brisk reflexes, positive Babinski sign and generally impaired coordination. Rectal exam showed normal tone.

What investigations should be arranged?

• Urinalysis
• Bladder scan
• Bloods – FBC, U&Es, ESR, CRP, Serum B12 and Folate
• Lumbar puncture (preceded by CT head)
• MRI spinal cord
• MRI brain

Urinalysis was normal. A bladder scan showed an empty bladder.

Initial blood tests showed the following:

Venous blood results
Haemoglobin	140 g/L
White cell count	6.0 × 10^9/L
Platelets	253 × 10^9/L
Sodium	139 mmol/L
Potassium	4.4 mmol/L
Urea	6.1 mmol/L
Creatinine	90 μmol/L

A lumbar puncture was performed, which showed the following:

Lumbar puncture results
CSF fluid	Clear
CSF protein	1.2 g/L
CSF glucose	4.1 mmol/L
CSF cell count	High
Plasma glucose	4.8 mmol/L
Gram stain	No organisms

The MRI spine is shown below.

Figure 1.1 (a) Sagittal T2 MRI image through the cervical spine; (b) Sagittal T1 images through the cervical spine; (c) The red line demarcates a long segment of abnormal T2 increased signal within the cord. Imaging diagnostic criteria for transverse myelitis involve the demonstration of long segments (3 to 4 vertebral body heights or more) of spinal cord signal change, occupying more than two-thirds of the cross-sectional area of the cord. These may demonstrate variable patterns of enhancement and restricted diffusion.

The MRI is reported as follows: altered T2 and gadolinium enhanced signal within the spinal cord from the level of C3 to C7, with no suggestion of any compressive/space-occupying lesion.

The clinical findings suggest a diagnosis of idiopathic transverse myelitis.

What are the diagnostic criteria for transverse myelitis?

The Transverse Myelitis Consortium Working Group suggests the following diagnostic criteria:

• Development of sensory, motor or autonomic dysfunction attributable to the spinal cord
• Bilateral signs and/or symptoms (though not necessarily symmetric)
• Clearly defined sensory level
• Exclusion of extra-axi...