cautionary tales
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Authentic Case Historiesfrom Medical Practice
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John Murtagh AMMBBS, MD, BSc, BEd, FRACGP, DipObstRCOG
Emeritus Professor, School of Primary Health Care, Monash UniversityProfessorial Fellow, Department of General Practice, University of Melbourne
Adjunct Clinical Professor, Graduate School of Medicine, University of Notre Dame, Fremantle WAGuest Professor, Peking University Health Science Centre, Beijing
Authentic Case Histories
from Medical Practice
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NoticeMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment anddrug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in theirefforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.However, in view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor anyother party who has been involved in the preparation or publication of this work warrants that the information contained herein
is in every respect accurate or complete. Readers are encouraged to confirm the information contained herein with other sources.For example, and in particular, readers are advised to check the product information sheet included in the package of each drugthey plan to administer to be certain that the information contained in this book is accurate and that changes have not beenmade in the recommended dose or in the contraindications for administration. This recommendation is of particular importancein connection with new or infrequently used drugs.
First edition published 1992This second edition published 2011
Text copyright 2011 John MurtaghIllustrations and design copyright 2011 McGraw-Hill Australia Pty LimitedAdditional owners of copyright are acknowledged on the acknowledgments page
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National Library of Australia Cataloguing-in-Publication Data
Author: Murtagh, JohnTitle: Cautionary tales : authentic case histories from medical practice / John Murtagh.Edition: 2nd ed.ISBN: 9780070285408 (hbk.)Notes: Includes index.Subjects: MedicineCase studies.
DiagnosisCase studies.Dewey Number: 616.09
Published in Australia byMcGraw-Hill Australia Pty LtdLevel 2, 82 Waterloo Road, North Ryde NSW 2113Publishing and digital manager: Carolyn CrowtherPublisher: Fiona RichardsonProduction editor: Claire LinsdellCopyeditor: Janice KeyntonIllustrator: Diane BoothCover and internal design: Astred HicksProofreader: Jess Ni ChuinnIndexer: Olive Grove IndexingTypeset in Berkeley, 10/14 by Mukesh Technologies, India
Printed in China on 90gsm matt art by iBook Printing Ltd
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v
Foreword
Problem-based learning is now established as the preferred method in clinical
medicine. Although our own medical education may have led us to believe
that a solid base of theoretical knowledge was needed on which to build our
clinical knowledge, the evidence of the past 40 years supports the view thatwe learn best by doing, by experiencing real-life situations, either personally
or vicariously through case histories. There is nothing new or startling about
this; all this century and well before it, educators have been saying this and
lamenting the relative paucity of problem-based learning in schools and
universities.
Through Cautionary Tales, John Murtagh has provided another rich
collection of case histories, which medical educators at both undergraduate
and postgraduate levels will find invaluable in teaching and learning. Thesecase histories are all the more valuable because they are enriched with the
psychosocial elements that form part of almost every patient problem and
every transaction between the patient and the doctor. Indeed these elements
are so central, that to ignore them in favour of the purely physical is to often
miss the point altogether. Medicine is still inclined to embrace the biomedical
model, to which can be attributed countless advances in medicine during
this century. But there are many phenomena that this limited model is
unable to explain. An expanded biomedical model, which weaves the weftof psychological, social and environmental factors into the biomedical warp,
will serve us and our patients much better. Cautionary Talesgives us many of
the examples we need to illustrate and understand this expanded model.
The addition of Discussion and lessons learned to each tale, and the
use of the questioning format, further enhances the value of the tales. Drawn
mostly from Professor Murtaghs own practice in rural Victoria, where literally
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Foreword
anything can and often does happen, they have an authenticity that the
artificially created case history can never match.
Educators will find Cautionary Talesa source of excellent material for
teaching and learning, and learners too will derive from them pleasure,insight and wisdom as well.
W. E. Fabb, FRACGP, FRCGP
Foundation National Director of Education, Family Medicine Programme, AustraliaPast Professor of Family Medicine, Chinese University of Hong Kong
Past CEO, World Organization of Family Doctors (Wonca)
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Contents
Foreword v
Preface xv
Acknowledgments xvii
1 Embarrassing moments 1
Black spot 1Smart alec prognostications 1
With friends like these 2
Tails of the unexpected 2Wrong injection, wrong person 3Blood donor to recipient in four days 3Oopswrong bedroom! 4Caught out by the law 4
A forgotten home visit 5Whos Bill? 6Unexpected obstructions, including dead people 6
An uninteresting problem! 7Are you trying to kill me, Doc? 8Better out than Ricky Ponting! 8
What do you think? 9The asthma inhaler shemozzle 9
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2 Great mimics 11
Cupids disease 11A super mimic 12
Alive, well and not to be forgotten 14Thoroughly analysing Milly 16
A pain in the butt 18Polymyalgia rheumatica: mimic supreme 20Coeliac disease: a disease of many faces and ages 22Chest pain of unusual cause 23
An unusual presentation of a common disorder 25She was, of course, a doctors wife 28The sinister modern pestilence 29Premarital syphilis or a rash decision? 30
All that wheezes is not asthma 31Great mimics: some concluding reflections 33
3 Masquerades and pitfalls 34
Four brief histories of a great pretender 34The dramatic tale of Hollywood Tomsurgeon
extraordinaire 35
Getting out of rhythm 37Paling into significance 38The high-spirited schoolteacher 40
Alcoholics anonymous: two sagas 42Zosterthe red face condition 45Not in the script 46Toxic shock? 47Perplexing chest pain 49
A classic golden trap 51Tales of Campylobacter jejuni 52
4 Endocrine tales 55
Death without a diagnosis for chronic fatigue 55A lighter shade of pale 57Missing links 59
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An overactive thyroid and an underactivecerebral cortex 61
The bomb happ y soldier 62Sleeping sickness 63
A bronze medal 65Diabetes with a difference 66Insulin stopwork 68The last rites: 12 years premature! 69Too big for their boots 71
A real headache 73
5 Sinister, deadly and not to be missed 76
Neisseria meningitidesmodern day black death 76Stress, angina, smokes, Viagra and angor animi 77Guess what? 79Lethal family histories 81The wrong pipeline 84I think shes carked it 86IUDs and ectopic pregnancy 88Unravelling problematic asthma 90
Living with ones mistakes 92Sidetracked 94Keeping a stiff upper lip 95
A snake in the grass 97A female relative with irritable bowel syndromeor
a red herring? 99Warfarin and INRa dangerous game 100
6 See a doctor, support a lawyer 102
21 years of iatrogenic abdominal pain 102A lost cause is a lost testicle 103Ignorance is not bliss 104The need for X-ray vision 107
X-rays and human error 109Are you playing Russian roulette with your patients? 111
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Underestimating motor mower power 113Beware children and needle-sticks 115
7 Red faces 116
The prescription pad 116Tonsillitis: traps for the unwar y 117
Vaginal tamponade 118Big-headed and pig-headed 119Six years of unnecessary nocturnal hell 120
Watching your Ps and cues 123He needed surger y like a hole in the head 124Mistreated depression in a middle-aged woman 126
8 Crisis and death 128
Picking up the pieces: the aftermaths of three deaths 128The kernel of the tragedy 130
A cruel world 133The sting of death: chilling visits 135Haunting images of lifeless children 138
9 The concealment syndrome 141
The ticket of entry 141Muriel, the stubborn one 143The concealment enigma: why is it so? 144Fitting the drug abuse jigsaw together 147Distracted by mothers presence 149Paper-clip problems 150
10 Families in conflict 152
Their first baby 152Throwing baby out with the bathwater 153Lame duck survival 155
An unplanned pregnancy: dj vu! 156
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11 Tales of the unexpected 159
Abdominal pain beyond belief 159If you dont put your finger in ! 161
Twin trouble 163Inherited suntans 164The past revisited 165Not an easy game 167
An unkindness of cancers 169An impossible hole in the head 172Worm tales 174Sheepish business 176
12 Sacked and rejected 177
Sacked 177The widows rejection 179101 obstetric ways to be sacked 182
13 Musculoskeletal twists and turns 185
Myalgia beyond tolerance 185
A Yankee bug in Oz 186The painful knee: search north 188The thumb that pulled out a lemon 189
A lost grand final 191By heck, watch the neck! 193Gout in little, old, religious ladies 195Beware the fall from a height 196Sniffing out the anatomical snuff box 197
14 Special senses 199The eyes have it: five short case histories 199
An awful earful 201Unusual causes of ear pain 203Pruritic skin rash beyond tolerance 204Pruritus sine materia(itch without physical substance) 206
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An unwanted Caribbean souvenir 208Summer and Pseudomonas 208Oh for a suntan! 209
15 Sexual twists and capers 211
The mountain maid 211One and one make nothing 212Mountains and molehills 214
A novel way to treat pruritus vulvae 216Marital surprises 217Fretting for mature love 219Traumatic sex 219
Pearly penile papules 220
16 Feverish problems 222
Pyrexia in the cowshed 222Yellow face syndrome 224Time-clock fever: each day at 4 pm 225Pyrexia in an Asian migrant 227Fever from the tropics 229
Beware the sweats by night 231The febrile Filipino bride 233Keeping an open mind 233
A truly cryptic infection 235
17 Neurological dilemmas 236
The bothered and bewildered amnesic patient 236All locked in 237
A breathtaking episode of post-flu fatigue 238Real headaches 239Hip-pocket nerve syndrome 241Fits and funny turns: the case of Terryanne 242Tremors and shock waves 244Two fishy tales 245
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Contents
18 Children and brain-teasers 249
The little girl who loved red and blue Lego 249Beware the childhood dysplastic hip 250
Three children with blunt abdominal trauma 251Deadly little bugs in little children 253The scared little boy with insomnia 255Bones and abdominal groans 257
Vertigo in children: two cases of scarlet face 259The incessant febrile convulsion 261Ingesting lethal iron tablets: but how many? 262Nightmare on paper only 263
19 Growing old 267
The rejected patient who was robbed by her doctor 267Slowing up: its just old age or is it? 268Decisions, decisions in the elderly 270Medicine by the sackful 272Old-timers and Alzheimers 274Costly waterworks 275
20 Mysteries of the mind 277
The challenge of assessing alleged assault 277The man who cried wolf! 278No lead in his pencil 281Lung cancer and the de facto issue 282
A certain kind of madness 284Problems with pethidine 287Some sort of vascular phenomenon 290
21 Emergencies, home and roadside visits 293
A shock to the system 293A shocking tale 294Dont work in the dark! 295Home visits: three cautionary tales 297
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Urgent calls to the toilet 300A black hole and black snakes 302Collapse in the hairdressers chair 305
A life-saving drill hole 305
22 Lessons in communication 307
Marriage breaks your heart! 307Communicating the bad news of HIV infection 308Careful what you say! 309Putting the foot in it 310Nocturnal spasms 311
A doctors heartburn 313
The case of the odd breast lump 314Doctor, watch your words 315
A personal encounter with a mystery illness 316
23 Odd syndromes 320
The wet paint syndrome 320The hubris syndrome 322The copy cat syndrome 323
Children with abnormal features 324The country dunny syndrome or rural flu 326
24 Cautionary methods: towards a safe
diagnostic strategy 328
The basic model 329Some examples of application of the model 336
Index 339
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xv
Preface
To practise medicine is a privilege, to practise it well is a difficult challenge,
but not to learn from ones mistakes is unforgivable.
Cautionary Talesis a collection of authentic case histories encountered
over 44 years of practising medicine, especially during 10 years of intenseyet wonderful general practice in a country area of Victoria, Australia. During
this time in practice with my wife, Dr Jill Rosenblatt, it was our privilege
to be the sole practitioners to a hard-working farming community of 2700
people. The practice was located in a small township with a twelve-bed Bush
Nursing Hospital. The area, which was mountainous bushland with a snow
resort, was popular with tourists. Many of the tales pertain to my experiences
in this community where we came to know our patients so wellboth
professionally and personally. They reflect the intensely human side ofour calling and to share them is a special privilege. It is also appropriate
to ponder on the humorous side of some of our experiences as well as the
inevitable tragic outcomes for so many that we remember with sadness.
The concept of, and impetus for producing, a series of cautionary tales
followed the obvious fascination of my medical students who considered
they learned so much from them, especially when they realised they really
happened and were certainly not apocryphal however embellished in
presentation. With the encouragement of some colleagues I decided topublish them regularly inAustralian Family Physician, the official journal
of the Royal Australian College of General Practitioners. The series has
become immensely popular and many practitioners have contributed their
own cautionary tales over many years. Several of their interesting tales are
included in this book.
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xvi
Preface
Writing these histories (which probably represents some type of catharsis
for the writers) for general consumption has its risks, but we feel that sharing
our experiences and messages is an important contribution to continuing
medical education. In particular, the cautionary advice about so manypitfalls is extremely useful to the inexperienced doctor facing up to the vast
challenge of general practice. There has been a focus on the medico-legal
dimension of the tales, so that we can develop a healthy awareness of the
pitfalls of our shortcomings, especially the missed diagnosis. I believe that the
subject matter covered in this book is a reasonably accurate reflection of the
common traps facing doctors in Western medicine. The tales are presented
under headings that capture the nature of the message. The book concludes
with an overview of a strategy that may help to keep the margin of error to aminimum.
Good judgement is based on experience. Experience is based on poor judgement.
I trust that our shared experiences promote a certain wisdom and better
judgement.
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xvii
The author would like to acknowledge the part played by the publication
division of the Royal Australian College of General Practitioners for
encouraging the concept of Cautionary Talesand for their permission to
reproduce much of the material that has appeared inAustralian FamilyPhysician. I acknowledge also the many practitioners who have supported the
series through individual contributions or through popular support.
Individual contributions to this book have come from the following
general practitioners to whom I am indebted:
Peter Baquie: Doctor, watch your words, Tales of Campylobacter jejuni
Karen Barry: Beware the sweats by night
Frank M. Cave: A shock to the system; Diabetes with a difference
Jim Colquhoun: The concealment enigma: why is it so?; The widows
rejection; Lame duck survival; The ticket of entry;
Problems with pethidine; Missing links; Not an easy
game; Alive, well and not to be forgotten; Sacked; A
certain kind of madness; An unkindness of cancers
Brian Connor: Decisions, decisions in the elderly
Trish Dunning: Insulin stopworkChris Fogarty: Saga 1: Hot flushes (in Alcoholics anonymous)
Andrew Fraser: She was, of course, a doctors wife; Home visits: three
cautionary tales; A doctors heartburn; Dont work in
the dark!
Peter Graham: No lead in his pencil
Acknowledgments
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Acknowledgments
Wadie Haddad: Pyrexia in an Asian migrant; Chest pain of unusual cause
Wayne Herdy: An unusual presentation of a common disorder
Christopher Hill: Careful what you say!; Glimpses of a cruel world
Warwick Hooper: A Yankee bug in Oz
Don Lewis: Sidetracked
Robert Lopis: A personal encounter with a mystery illness
Lance Le Ray: Some sort of vascular phenomenon
Donna Mak: Marital surprises
Hugo Matthews: A super mimic
Breck McKay: Thoroughly analysing Milly; Fits and funny turns:
the case of Terryanne
Paul Niselle: Putting the foot in it
Amanda Nutting: Paper-clip problems
Anthony Palmer: Summer and pseudomonas
Andrew Patrick: A real headache
Leon Piterman: Big-headed and pig-headed; IUDs and ectopic pregnancy
Geoff Quail: Oh for a suntan!
Philip Ridge: Beware children and needle-sticks
Ralph Sacks: A bronze medal
Lyn Scoles: Slowing up: its just old age . . . or is it?
Leslie Segal: Keeping a stiff upper lip
Chris Silagy: The high-spirited schoolteacher
Roger Smith: Keeping an open mind
Gino Toncich: Case 1: The child who died (in Two fishy tales)Alan Tucker: The prescription pad
Bill Walker: Twin trouble
Alan Watson: Are you playing Russian roulette with your patients?
Special thanks to Nicki Cooper and Jenny Green for typing the text.
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xix
A NOTE TO READERSMany of the tales in this book have cryptic headings so that the diagnosis is
not apparent. You are invited to analyse the case history and study the clinical
findings and the minimal information to make a provisional diagnosis priorto reading the part describing the diagnosis and outcome. All of these cases
are authentic, but most of the names of patients and their spouses have been
altered.
Acknowledgments
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141
The ticket of entryMARGOT
Doctor, its Margot. I think Ive got the shingles again: theres another rash on
my right leg. What do you think?
I think wed better take a look. Come in later this afternoon.
Margot arrived and there were a few spots on the leg previously affected
by shingles, but they were not typical of her recent virus: they were itchy
rather than painful.
Its certainly not shingles. How do you feel generally?
I feel terrible, she said and then burst into tears.
The rash had been a ticket of entry.
Margot then explained how tense, irritable and depressed she had been
since her husband had retired. Jack, under pressure from his wife, had
chosen early retirement at 60, despite excellent physical and mental health.
It was thought that now the family had grown up there would be time for
them to do things together. The reality was quite different. Hes there all the
time; keeps getting under my feet. I love him so much and yet Im unpleasant
to him. I feel that because hes at home Ive been demoted from captain to
lieutenant. The consultation went on in this vein for a long time.
CHAPTER
The concealmentsyndrome
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I first heard the expression ticket of entry from my partner, Geoff
Ryan, Foundation Professor of Community Practice at the University of
Queensland. He had coined the phrase during a discussion about the
ways patients would conceal their reasons for seeking advice. Hesitation
to broach the subject immediately could be due to many factors: guilt
and embarrassment, as in Margots case; fear of the unknown (or known);
inability to discuss personal matters easily; or apparent loss of face.
HARRY
Harry was a 35-year-old strong healthy, man who earned his living by laying
concrete and prided himself on his physique and strength of character.Its this elbow again, Doctor. I think Ill need the injection after all; I cant
do my job properly.
I examined, concurred and gave the injection of steroid.
You knew I was a professional marksman? said Harry. I had to confess
that I did not. Im having terrible trouble with palpitations before the big
events: puts me right off. Can you do anything to help?
I sat down to tackle the real reason for the consultation: his macho
image had been eroded. Fear is a common reason for use of the ticket.
MRSM
Mrs M was a woman in her forties who kept good health and was only an
occasional patient. I had not seen her for some time.
Im due for my Pap smear.
After checking her card to confirm her last result I followed the routine
procedure. I asked if she did regular breast self-examination. She replied,
I came here today because theres a lump in my right breast. There was.
GERRY
Gerry, a large, masculine, A-grade squash player in his mid-30s, was mildly
hypertensive and overweight. He appeared one day, concerned about his
weight and its effect on his knees and ankles. We discussed it fully.
Jenny has been complaining. I waited for him to elaborate on his wifes
complaint. I cant maintain an erection. Embarrassment and macho loss
were evident once more.
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Chapter 9 The concealment syndrome
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DISCUSSION AND LESSONS LEARNED
These are our examples o a common phenomenon in general pracice.
In my experience his delay in geting o he poin occurs when he problem
is personal: marial upse, breakdown o a relaionship and, mos ofen, he
embarrassmen o discussing a problem o a sexual naure.
The message or he general praciioner is o be paien during he
consulaion. The apparen reason or presenaion migh be a mask ha
will be raised evenually o reveal he rue ace. People can find i difficul o
open up o heir docor immediaely, no mater how comoring or relaxed
we hink we are.We mus ry o discipline ourselves agains irriaion when, having solved wha
seems o be he obvious problem, we find i is only a icke o enry.
Muriel, the stubborn oneMuriel, aged 62, had severe hypertension. For several years it remained in
the vicinity of 220/120, despite medical attention, and so I referred her to a
hypertension clinic at the teaching hospital.
Except for left ventricular hypertrophy, the results of all investigations
were normal and many drug combinations were tried: potent drugs, the most
recent drugs, permutations and combinations. Her blood pressure remained
immovable. I kept asking Why?
Yes, of course I take the drugs you prescribe, Doctor.
I have only a social drink, Doctor.
I plotted strategy: I stopped all her antihypertensives and prescribed
phenytoin 300 mg daily. On review I took a blood sample: the test returned a
serum phenytoin level of zero. Poor Muriel, as suspected, was not taking any
tablets.
When I tactfully confronted her she was unrepentant. I dont want to
take any tablets. I generally feel well; when I take the tablets I dont.
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DISCUSSION AND LESSONS LEARNED
Paien non-compliance is more common han we realise and we mus always
be aware o he possibiliy o paiens no aking heir drugs i an expeced
herapeuic response does no evenuae.
Prescribing a relaively non-oxic drug ha can be quaniaively measured is a
useul means o checking compliance.
The concealment enigma: why is it so?Duke:And whats her history?
Viola:A blank, my Lord: She never told her love,
But let concealment, like a worm i the bud,
Feed on her damask cheek: she pind in thought;
And, with a green and yellow melancholy,
She sat, like patience on a monument,
Smiling at grief. W Shakespeare, Twelfth Night, Act II, Scene IV.
MRSA
Mrs A sat on the edge of the beda 66-year-old woman, deathly pale, wet
with cold perspiration, obviously in extreme distress. The pain described
was classic: retrosternal, crushing and radiating down the left arm. She had
a long history of hypertension with ischaemic heart disease. This night her
blood pressure was very low, the tachycardia rapid but regular, and the painsupreme. A definite myocardial infarct. Despite the distress she was reluctant
to bare her chest. The reason was soon evident. In the upper outer quadrant
of the left breast was a hard ulcerated carcinoma of the breast, which had
been there for well over a year. (Refer to Figure 9.1, centre insert page 5.) She
had told no one, not even her husband.
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Chapter 9 The concealment syndrome
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MRSY
Mrs Y always accompanied her husband on his routine visits: she literally
led him by the hand. He had a long history of peripheral vascular disease
and controlled cardiac arrhythmia. Arthura pleasant, chatty, ingenuous
manneeded looking after. His wife always wore a headscarf. One day
with some embarrassment she removed it. The right ear was absent
replaced by an invading basal cell carcinoma. Though it had been present
for at least 18 months no one had been informed. Her husband had not
noticed it.
MRB
I was introduced to Mr B by his wife, who said there was something wrong
with his upper lip. I looked at what I thought was an untreated harelip
and cleft palate, in a small, thin, aggressive 61-year-old who did not like
doctors. He had otherwise been in perfect health and obviously thought
his lip would get better if ignored. His wife, risking his displeasure,
had taken her courage in both hands and called me. A rodent ulcer had
eroded half his upper lip through to the nasal septum, giving the harelip
appearance.
MRSG
Mrs G, a lady of 54 years of age, was pale, thin, already cachectic. She sat
up weakly in bed in a pink dressing gown while her husband stood guiltily
in the background. The air in the bedroom smelt of putrefaction. In tears
she slipped off the dressing gown to reveal the fungating remnant of her left
breast. Axillary lymph glands were easily palpable and a pleural effusion
present, yet she had told no one. Her husband said he did not know about it.
In the presence of such obvious illness and deathly odour, how could it have
been missed?
How can this possibly happen?Those of us who have been in general practice for any length of time have
seen such cases and never fail to be surprised or even horrified by them. They
are good examples of the phenomenon of concealment. It commonly but not
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always occurs in happily married older people when the bloom of youth and
sexual communication have gone.
Why do these people suffer in silence? Fear of what is believed to be
inevitable? Protection of the beloved spouse? Dismissal as an unacceptable
occurrence? A fatalistic philosophy? In many instances it is not lack of
intellect, because these patients cover the full spectrum of intelligence.
Whatever the reason it is a heartbreaking and sickening experience for the
doctor who is unfortunate to be present at the unveiling; his or her presence
like a prophet of doom.
And what became of these victims of concealment?
The lady who had the infarct while concealing her breast is still alive but
her cardiac state is critical. We are all hoping this will solve the problem of
other medical decisions.
The protective lady who led her husband by the hand is now a
widow: her husband had a fatal heart attack. She had the ear remnant and
supporting tissue removed, now wears her hair long and spurns an expensive
artificial ear.
The man with the upper lip neoplasm is hale, hearty and as aggressive as
ever. A series of constructive repair procedures over many months looks likea successful repair of an old harelip.
And the lady with the ulcerating, fungating breast neoplasm? She suffered
a painful, emaciating, lingering death. I still see her husband regularly. He has
never mentioned her since.
DISCUSSION AND LESSONS LEARNED
Every docor should be aware ha some people, or a variey o reasons,
conceal heir illnesses. The compeen docor, aler or signs o his, can make
he opening or which he paien is waiing.
This requires a all imes he exercise o sensiiviy, undersanding and ac.
Someimes a docor will develop a sixh sense o percepion ha he paiens
presening sympoms are no hose ha are mos worrying him or her, or in
mos need o atenion.
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Chapter 9 The concealment syndrome
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Fitting the drug abuse jigsaw togetherCASE 1
Michelle G, a 14-year-old schoolgirl, presented with colicky abdominal pain
of two months duration. Apart from some anorexia and nausea there were
no associated symptoms, such as a change in bowel habits or evidence of
menstruation-related pain. She had visited a naturopath who said it was
irritable bowel and who provided dietary advice plus some medicine. In
taking the history I asked casually, How many cigarettes do you smoke each
day? The furtive glance between mother and daughter was highly significant.Before she had time to deny it I asked, Six, ten or twenty? Just a few, came
the sheepish reply.
I informed her surprised mother, Michelle has the problem of
schoolgirls colica common problem in those starting smoking (nicotine)
cigarettes. Nicotine is a drug and can cause these physiological effects,
which soon settle but its best to quit now. They went home with advice and
handouts on quitting smoking.
CASE 2
Peter S, aged 23, presented because he was feeling flat and listless. His
parents who accompanied him claimed he wasnt himselfhe was bored,
lazy, apathetic and did not care about his work on the farm. He would not get
out of bed to milk the cows and had been in trouble with motor accidents,
and law and disorder.
Peter seemed unwell, apathetic and uninterested in the consultation.
While taking a history I gained the impression that he was schizoid although
he denied any auditory hallucinations. How much pot, grass or dope are you
smoking Peter?
Yeahquite a biteveryones smoking the stuff. His parents had no
idea that he was smoking it.
CASE 3
Mandy E, a 16-year-old schoolgirl was being nursed at home for suspected
gastroenteritis. I was asked to visit her because she was very sick and her
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abdominal pain more intense. Pelvic appendicitis, I thought en route to the
humble home in a small township. Her mother claimed, Shes been acting
strange, has twitches in her muscles and is yawning a lot today. She had a
two-day history of nausea, running eyes and nose, colicky abdominal pain
and diarrhoea. Physical examination was normal.
I was aware that heroin had been introduced into the area. Mandy was an
obvious case of heroin withdrawal.
CASE 4
Hal J, a 42-year-old actor, came to see me because he had collapsed late
one evening. Hes been working his butt off and is physically and mentally
exhausted, claimed a friend who brought in the fidgety, sweating and
floppy patient. His blood pressure was 180/110 and his pulse 102. I
performed an ECG, which showed runs of ventricular premature beats.
I admitted him to hospital where he became very languid, irritable and
aggressive (at times), and ground his teeth incessantly. After 24 hours
he became very paranoid and apparently psychotic with disorganised
thinking.
It was obvious that he was having a withdrawal from a stimulant drug(perhaps amphetamines). I asked him and his associates about this possibility
and determined that he was taking crackthe stronger alkaloid derivative of
cocaine.
DISCUSSION AND LESSONS LEARNED
All hese cases illusrae he wide variey o maniesaions o subsance abuse,
each represening a diagnosic conundrum. Cocaine is a raher overpowering
drug bu no less dangerous is our mos serious drug problemnicoine abuse.
We have o suspec drug abuse, especially in eenagers and hose who may be
exposed o he drug scene presening wih poor healh, unusual sympoms, and
changes in personaliy and school perormance. An apparen psychoic episode
may also be a srong poiner o abuse o hard drugs.
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149
Distracted by mothers presenceMeredith was a 23-year-old trainee lawyer who presented to our practice
with a gastrointestinal disturbance. She was seen by the GP registrar and was
accompanied by her mother who was a rather severe and clinging personality.
She would give the history in tandem with her daughter who did look
somewhat pale and distracted.
Meredith had a past history of migraine and anorexia nervosa.
She had been quite well in the previous few years while she completed
her law degree and had attended the practice for prescriptions of the oralcontraceptive pill.
Her presenting complaint was anorexia and nausea with mild left colicky
abdominal pain. She had loose bowel actions and had vomited three times
in the past 12 hours. On examination her vital signs were pulse 64/min,
BP 100/65, temperature 36.7 C, RR 14/min. On abdominal examination
there was mild tenderness in the left flank and left iliac fossa while the rectal
examination was normal.
I agreed with my colleague that the diagnosis was rather obscure but
that a working diagnosis of gastroenteritis was appropriate. She was sent
home with the advice to ring us at the surgery if there were any further
problems.
Mother rang the next day to say that she was worried about Meredith
because of increased colicky pain and discoloured urine. I went on a home
visit and found the patient looking worse than the previous day and certainly
wan and depressed. Mother remained in the thick of the process offering her
own differential diagnoses. The urine specimen contained blood and she now
had dysuria and I wondered about possible acute pyelonephritis although she
was afebrile.
I organise her to attend a colleague at a nearby emergency facility for
investigations including FBE, ESR, MCU and renal ultrasound. The FBE was
normal (including platelets), ESR 45 and the ultrasound revealed obstruction
of the left renal pelvis probably due to blood clot. An INR ordered by my
astute colleague was 7.0. Strange. So a more detailed history was taken.
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Would you believe Meredith had been feeling depressed to the point she
felt suicidal? She started to ingest Ratsak, which she understood would be
an effective poison. However, after a few days nothing much was happening
apart from the sick feelings and she now felt extremely stupid about her
actions and believed that if she kept quiet then the substance would dissipate
and no one would need to know.
DISCUSSION AND LESSONS LEARNED
Once again he imporance o a good amily hisory is highlighed.
Be somewha scepical especially i he siuaion seems unusual and don
assume ha nice people don do weird hings.
I you sense ha i is appropriae see he paien alone i possible. I may be
necessary o diplomaically ask anoher person, relaive or riend, o leave he
room.
Ask he paien wha hey consider is heir real problem.
Always believe and ake cognisance o a mohers concern.
Paper-clip problemsHow often have we been caught out by the paper-clip trap whereby a loose
A4 page gets inadvertently attached to the back of an unrelated document
when it is bound by a paper clip? A vain search for the document may follow.
All may be revealed when the lost is found in a week, a month, or even a
years timeor never!
Mrs CS, a 43-year-old lawyer, received a paper copy of her Pap smearresult together with the vaginal swab results of another patient. They were
posted out from our practice following the sequence of GPpractice nurse
receptionistpatient.
Mrs CS phoned to express her displeasure at this clanger and organised
to return the report to the practice for shredding according to confidentiality
protocol. The error occurred when the reception staff clipped the results of
the two different patients together. The error was not detected by the doctors
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Chapter 9 The concealment syndrome
checks, the computer or by the reception staff printing the address stickers.
A letter of apology to both patients followed and the practice reviewed its
policy of handling paper results.
DISCUSSION AND LESSONS LEARNED
Alhough his inciden did no compromise paien healh i was unproessional,
embarrassing and poenially liigious.
In our pracice paper clips are no longer used or he collaion o paiens
resuls or repors.
Oher remedial sraegies include: docors and pracice nurses careully
scruinising every paper repor and recepion saff checking he conen o all
envelopes o be posed prior o sealing hem.
Paperless records will be he answer o many pracice managemen problems.