Cautionary Tales

8/12/2019 Cautionary Tales

1/32


2/32

Authentic Case Historiesfrom Medical Practice


3/32


4/32

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


5/32

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

Every effort has been made to trace and acknowledge copyrighted material. The authors and publishers tender their apologiesshould any infringement have occurred.

Reproduction and communication for educational purposesThe Australian Copyright Act 1968(the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever isthe greater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that theinstitution (or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and beengranted a licence. For details of statutory educational and other copyright licences contact: Copyright Agency Limited, Level 15,233 Castlereagh Street, Sydney NSW 2000. Telephone: (02) 9394 7600. Website: www.copyright.com.au

Reproduction and communication for other purposesApart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of thispublication may be reproduced, distributed or transmitted in any form or by any means, or stored in a database or retrieval system,without the written permission of McGraw-Hill Australia including, but not limited to, any network or other electronic storage.

Enquiries should be made to the publisher via www.mcgraw-hill.com.au or marked for the attention of the permissions editor atthe address below.

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


6/32

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


7/32

vi

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)


8/32

vii

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


9/32

Contents

viii

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


10/32

Contents

ix

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


11/32

Contents

x

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


12/32

Contents

xi

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


13/32

Contents

xii

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


14/32

xiii

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


15/32

Contents

xiv

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


16/32

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.


17/32

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.


18/32

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


19/32

xviii

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.


20/32

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


21/32


22/32

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


23/32

Cautionary Tales

142

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.


24/32

Chapter 9 The concealment syndrome

143

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.


25/32

Cautionary Tales

144


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.


26/32


145

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


27/32

Cautionary Tales

146

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.


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.


28/32


147

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


29/32

Cautionary Tales

148

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.


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.


30/32


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.


31/32

Cautionary Tales

150

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.


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


32/32


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.


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.

Documents

Cautionary Tales