Expect the Unexpected

By Chia Yook Chin and Ng Wei Leik

Expect the Unexpected: A Compilation of Common Clinical Cases Posing as Diagnostic Dilemmas is a comprehensive anthology of cases featuring frequently encountered patient presentations in medical practice, with a focus on highlighting the diagnostic complexities. The curation stems from the years of experience and challenges faced by the authors. In each scenario, readers will find practical takeaways and succinct medical insights. These are aimed at fostering critical thinking and empathy skills among medical professionals. This book is also designed to help budding medical students, interns, as well as general medicine and family medicine trainees, to be familiar with the unfamiliar.

 

"Expect the Unexpected will greatly benefit family physicians at different stages of their careers and also to clinicians providing first contact with patient care. This book is strongly recommended to enhance [medical practitioners'] expectations for unexpected clinical conditions."

 

Prof Albert Lee, MBBS DCH MPH MD FRACGP FRCP Hon FFPH

Emeritus Professor of Public Health and Primary Care, The Chinese University of Hong Kong,

Department of Paediatrics and Adolescent Medicine, HKU

• Language: English
• Publisher: Sunway University Press
• Release date: Jan 1, 2024
• ISBN: 9786297646015

Book preview

EXPECT THE UNEXPECTED: A Compilation of Common Clinical Cases Posing as Diagnostic Dilemmas

Chia Yook Chin

Ng Wei Leik

Copyright © 2024 by Sunway University Sdn Bhd

Published by Sunway University Press

An imprint of Sunway University Sdn Bhd

No. 5, Jalan Universiti

Bandar Sunway

47500 Selangor Darul Ehsan

Malaysia

press.sunway.edu.my

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, now known or hereafter invented, without permission in writing from the publisher.

eISBN 978-629-7646-01-5

Cataloguing-in-Publication Data

Perpustakaan Negara Malaysia

A catalogue record for this book is available from the National Library of Malaysia

Edited by Ivan Ling

Designed and typeset by Rachel Goh

Cover image: eggeegg/Shutterstock.com

Image used under licence from Shutterstock.com

REVIEW

The case studies of Expect the Unexpected written by Professor Chia Yook Chin and Dr Ng Wei Leik provided me with numerous insights into searching for unexpected clinical events. Reading these cases offered me an excellent opportunity to continue developing my profession as a medical practitioner. With that said, the challenge and dilemma faced by family physicians in daily practice is the inability to differentiate self-limiting health conditions from possible serious underlying pathologies. Patients usually present non-specific symptoms or signs, and family physicians need to be very cautious not to over-investigate but also not miss potential life-threatening conditions. What are these cues for a detailed workup? How and where would we strike the balance?

This compilation enables us to become more alert of potential red flags, symptoms, and signs to consider severe hidden illnesses as diagnostic possibilities. The authors have determined how to establish these diagnostic hypotheses through meticulous history taking and appropriate clinical examination—managing the cases with effective use of time as a diagnostic tool and the rational use of more intensive investigations. The book also illustrates how some cases are safe to observe and monitor, but would require comprehensive and holistic care while considering physical and psycho-social perspectives before making the diagnosis.

In every case, background information is provided with good references, helping to refresh our knowledge and problem-solving skills in managing clinical uncertainties. The learning points are also important take-home messages. Expect the Unexpected will greatly benefit family physicians at different stages of their careers and to clinicians providing first contact with patient care. This book is strongly recommended to enhance our expectations for unexpected clinical conditions.

Albert Lee, MB, BS, DCH, MPH, MD, FRACGP, FRCP, Hon FFPH

Emeritus Professor of Public Health and Primary Care,

The Chinese University of Hong Kong,

Governor of Board of World Association for Medical Law,

Member of Education Committee, Australasian College of Legal Medicine.

CONTENTS

Foreword

Preface

Introduction

SECTION 1 HEADACHES

Case 1 21-year-old man with recent headache

Case 2 52-year-old man with five months of headache

Case 3 22-year-old woman with one week of headache

Case 4 32-year-old man with one week of headache

Case 5 30-year-old woman with headache for 10 years

Case 6 40-year-old woman with a demand for an investigation

Case 7 18-year-old man with new-onset headache 25

Case 8 58-year-old woman with headache post-COVID-19 vaccination

SECTION 2 GENITOURINARY CONDITIONS

Case 9 16-year-old girl with dysuria

Case 10 65-year-old woman with Type 2 diabetes mellitus and urinary tract infection

Case 11 58-year-old man with microscopic haematuria

Case 12 41-year-old woman with dysuria

SECTION 3 TIREDNESS

Case 13 32-year-old man with tiredness

Case 14 52-year-old woman with lethargy

Case 15 36-year-old woman with tiredness and breathlessness

SECTION 4 NEUROLOGICAL AND BEHAVIOURAL SYMPTOMS

Case 16 67-year-old man with unsteadiness

Case 17 20-year-old man with dizziness

Case 18 62-year-old sad woman

Case 19 82-year-old man who was not quite himself

Case 20 53-year-old man with loss of consciousness

SECTION 5 FEVERS AND COUGHS

Case 21 32-year-old woman with haemoptysis

Case 22 52-year-old woman with one week of fever

Case 23 4-year-old child with fever

Case 24 21-year-old man with high fever

Case 25 56-year-old woman with chronic cough

Case 26 32-year-old man with fever and cough

Case 27 16-year-old girl with chronic cough

Case 28 25-year-old man with fever

Case 29 11-year-old child with intermittent fever

SECTION 6 PAIN

Case 30 32-year-old man with right iliac fossa pain

Case 31 34-year-old woman with multiple joint pains

Case 32 40-year-old woman with sudden onset of chest pain

Case 33 50-year-old man with chest pain

Case 34 56-year-old man with epigastric pain

Case 35 33-year old woman with abdominal pain for three years

Case 36 30-year-old man with backache

SECTION 7 MISCELLANEOUS

Case 37 32-year-old woman with facial swelling

Case 38 60-year-old man with abnormal liver function

Case 39 72-year-old patient on long-term follow-up for hypertension

Case 40 50-year-old man who cannot tolerate anti-hypertensive agents

Case 41 I want an X-ray!

SECTION 8 SOCIAL CHALLENGES ENCOUNTERED

Case 42 16-year-old girl with amenorrhoea

Case 43 36-year-old woman with abdominal pain for two months

Case 44 Angry patient shouting and arguing with doctor

Case 45 A baby with severe neonatal jaundice

SECTION 9 ESSENCES OF PRIMARY CARE

Case 46 40-year-old asthmatic patient

Case 47 Patients on long-term regular follow-up

Case 48 I want to see a specialist.

Case 49 A heartsink patient

Case 50 A sorrowful widow

SECTION 10 AVOIDABLE LAB ERRORS

Acknowledgements

About the Authors

Index

FOREWORD

Life is short, art long, opportunity fleeting, experience treacherous,judgement difficult

Hippocrates

There has been a long tradition in Medicine of learning from case histories, a tradition that sadly seems to have tapered off. As a parallel, storytelling, in nearly all cultures globally, has been a powerful medium for imparting learning and wisdom and one that carries the additional frisson of delineating right from wrong and what should have been done, akin to parables of morality. Of late, case studies are being incorporated more into the management and health policy fields, especially with the need to appreciate patients’ experiences with the health services. It is refreshing, therefore, to return to a series of clinicians’ own experiences around their encounters with patients and how their accounts can help us with our own consultations.

The essence of a good case history, one from which valuable pointers can be picked up, is the detailed and continuous account of what unfolded, combined with the essential elements of honesty and openness. No doctor is perfect in their decision making and the passage of time following a patient’s initial presentation can make previous diagnoses and care seem inadequate and misguided. In this book of cases, with openness and honesty, the authors recognise the difficulties of getting things right the first time, every time. They emphasise the need to return to the basics, with an open, objective mindset particularly when the patient needs to be seen again. Things do not always work out as we thought they would.

There is much to be learnt from these case histories, and it is commendable that Professor Chia and Dr Ng have put their experience to good use for us within an undercurrent of humanity and caring. Their experience covers many years of frontline exposure to acute emergencies as well as the routine follow-up of patients whose problems were initially inadequately resolved. The range of cases presented is wide-ranging with reflections on the ethical and legal dimensions when these are key features of the situation. The cases are presented in an accessible and readable manner, in a format that makes almost compulsive reading for a fellow doctor!

The good physician treats the disease; the great physician treats the patient who has the disease

William Osler

Professor Pali Hungin, OBE, DL, MD, FRCP, FRCGP, FRSA

Former Dean of Medicine, Durham University, UK

President, British Medical Association, 2017

PREFACE

I have been meaning to collate the stories of the patients whom I have managed and learnt from, to share with trainees. But alas, I have only managed to do so now because of competing interests and work demands. Here, together with my former trainee, Dr Ng Wei Leik, is a collection of cases I hope young doctors can learn from.

What actually spurred me to write this book is that during all my years in academia teaching both undergraduate medical students and postgraduate trainees, I shared with them cases I had managed myself or been consulted on by trainees, during the teaching, audit and case discussion sessions.

It was apparent to me that certain common conditions frequently present themselves in primary care, yet they can be very different. One example is headache, a common primary care problem that can carry very different diagnoses. Herein lies our need to be able to differentiate the conditions carefully so that the correct treatment is prescribed to the patient.

One might notice that this book is a collection of common presenting conditions and not so much of the rare, unusual cases seen perhaps only once in a lifetime or not at all.

While there is a lot of solid science behind the practice of medicine, the art is also crucial. Patients tell a very good tale about their illness. Hence, we must pay more attention to what they are saying rather than paraphrasing their complaints with our medical terminology. I remember what my professor of medicine said when I was a medical student: The chief complaint must be in the patient’s own words. I have found this to be very useful when trying to make a diagnosis.

In this age of computerisation and computerised medical records, we tend to miss a lot of information because we are too busy looking at the medical records on the computer screen when the patient comes into the consultation room. Again, I remember my professor saying that you can almost make a diagnosis the minute the patient walks in. I found this to be useful each time I see a patient and indeed, one of the cases in this book illustrates this.

Another aspect we need to remember in primary care is to keep reviewing patients at each follow-up visit especially when the initial diagnosis is not clear or confirmed, as frequently, more time is needed to make the correct diagnosis.

Finally, one of the greatest challenges for a primary care doctor is time. Frequently, doctors are required to see many patients in a session, each less than five minutes, at most ten, to carry out the necessary procedures. Hence it is not surprising that mistakes of missed diagnosis at the first encounter can be made. I hope this collection of cases will help doctors to better diagnose patients and for others not to be too critical when the diagnosis is not made at the first consultation.

Prof Dr Chia Yook Chin, MBBS, LRCP, MRCS, FRCP, FAFPM (Hon)

~

As a former student of Professor Chia, I had always listened to her encounters with patients during the teaching sessions. The nuances of family practice that we discerned in her stories can only be drawn from a vast experience of seeing many patients. They are not something that you would get out of a textbook. I like to think of it as a master sharing the secrets of the trade.

Something that I have consistently always appreciated about Professor Chia’s stories is her determination to find out what is wrong with a patient and her commitment to proper, thorough clinical assessment (both history and physical examination). This is something I hope to inspire in the next generation of doctors.

To this day, I still share some of Professor Chia’s many cases with our young students and doctors. I hope that this book is able to provide a glimpse into the many interesting cases that we encounter in our practice as primary care doctors.

Dr Ng Wei Leik, MBBS, MMed, AM (Mal)

INTRODUCTION

Making a diagnosis in primary care is hard.

I am referring this case to another specialist anyway; the diagnosis does not matter.

It’s not my job to come up with the final diagnosis.

We should only be dealing with simple cases in primary care.

Why bother diagnosing now? Lab tests and imaging will give me the answer.

These are some of the comments that some trainees and primary care colleagues say regarding primary care practice. Working in primary care, we often encounter the challenges of making a diagnosis in the face of undifferentiated symptoms, time constraints, and limited resources. There are times that we may feel content with passing the buck to others to make the diagnosis, as long as the patient is safe and sound. There are also times that we may feel that our skills in making a diagnosis from good old-fashioned history taking and physical examination are slowly being superseded by modern science and technology.

This book shares anecdotes of cases in primary care, most of which deal with diagnostic difficulties in the day-to-day challenges of managing patients from all walks of life. These stories are accompanied by learning points that we can garner from each case. These personal accounts of a primary care doctor will hopefully inspire other doctors, particularly the younger ones, to take pride in their profession and the age-old skill of evaluating a patient clinically.

Also included are some theoretical information and a list of references pertaining to each individual case. While they are not a substitute for proper formal study (particularly in this internet age where knowledge is continually updated), the concise information provided will hopefully offer new knowledge to readers with a quick read.

Think of this book as a compilation of short stories that you can read at leisure, while learning at the same time, akin to good old fables.

SECTION 1: HEADACHES

CASE 1

21-year-old man with recent headache

This patient first came to the clinic complaining of a headache of recent onset. A diagnosis of tension headache was made. He was given analgesia and was told to come for follow-up if he did not get better. He came the second time a week later and the same diagnosis was made. A different analgesic was prescribed to him.

By the time I saw him on his third visit, as a walk-in patient, his headache was of four weeks’ duration.

He described the headache as mild but all over the head. He could not really describe the nature of the headache but when asked directly whether it was band-like or throbbing, he said it was neither. The headache was not getting worse, but it was persistent although not very severe. It was not associated with fever, aura, neurological symptoms or symptoms suggestive of raised intracranial pressure. He was well before this with no history of head injury. He was not on any recreational drugs.

On examination, his visual acuity was 6/6 bilaterally but bitemporal hemianopia was detected. There was no papilloedema and all other neurological examinations were normal.

I proceeded to screen for a pituitary tumour and ordered a lateral X-ray view of the skull. The pituitary fossa was very enlarged. I ordered a serum prolactin test and it showed that the prolactin level was more than 1000 ng/ml. This confirmed a prolactinoma with compression of the optic chiasma.

I referred him to the endocrinologist and conservative treatment with bromocriptine was prescribed. He subsequently did not have any more headaches and his bitemporal hemianopia improved. His serum prolactin levels came down to near normal and a computed tomography (CT) scan of the brain showed only a slightly enlarged pituitary.

LEARNING POINTS

As usual, take the history and do the full physical examination yourself.

Do not assume all headaches in young individuals are tension headaches or migraine.

Usually, the deceptive thinking is that space-occupying lesions in the brain are associated with severe headaches. Instead, the opposite is more likely.

Always, always do a full neurological examination! This will include visual acuity, visual field, funduscopy and all the other cranial nerves, not just the power and reflexes. Upper neurological functions like memory should also be assessed especially in older individuals presenting with new-onset headaches.

BACKGROUND INFORMATION

Around 98% of all headaches are due to primary headache disorders such as migraine, tension headache and cluster headache. However, it is important to recognise secondary causes of headache. The consequences of missing a diagnosis such as brain tumour would