Title, Contents, Forewords, Preface

s PROBLEM-BASED MEDICAL CASE MANAGEMENT SECONI" EDITION Edited by Kathryn Tan 362.11068 P96

Problem-Based Medical Case Management Second Edition Edited by Kathryn Tan EEABHM

Hong Kong University Press The University of Hong Kong Pokfulam Road Hong Kong www.hkupress.org © 2017 Department of Medicine, The University of Hong Kong ISBN 978-988-8390-79-3 (Paperback) All rights reserved. No portion of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, includ- ing photocopy, recording, or any information storage or retrieval system, without prior permission in writing from the publisher. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. 10987654321 Printed and bound by Paramount Printing Co., Ltd. in Hong Kong, China

Contents (Books) == AUG 2017 Chapter 142 BOOKS REGISTRATION ORDINANCE Foreword by Sir David Todd Foreword to the First Edition by Sir David Todd Preface by Rosie Young and Kathryn Tan CARDIOLOGY Hung-Fat Tse 1. Cardiology—Short Cases Chu-Pak Lau, A. John Camm, Hung-Fat Tse, Kai-Hang Yiu, and Kathy Lai-Fun Lee Overview 1.1 Aortic regurgitation 1.2 Aortic stenosis 1.3 Atrial septal defect 1.4 Eisenmenger’s syndrome 1.5 Atrial fibrillation 1.6 Mitral regurgitation 1.7 Mitral stenosis 1.8 Mitral valve prolapse 1.9 Patent ductus arteriosus 1.10 Tricuspid regurgitation 1.11 Ventricular septal defect Examination case scenarios Xiv xVvi xviii

vi Contents 2. Cardiology—Long Cases Chu-Pak Lau, A. John Camm, Kai-Hang Yiu, Wai-Hong Chen, and Bernard Man-Yung Cheung 2.1 22 2.3 2.4 2.5 2.6 Acute chest pain (acute myocardial infarction) A patient with progressive exertional dyspnoea (dilated cardiomyopathy) Exercise induced syncope (hypertrophic obstructive cardiomyopathy) Fever for three months (infective endocarditis) A patient with high blood pressure (malignant hypertension) Advice on pregnancy (mitral stenosis) ENDOCRINOLOGY AND GENERAL Karen S. L. Lam 3. Endocrinology and General—Short Cases Karen Siu-Ling Lam, James D. Best, Kathryn Choon-Beng Tan, and Chi-Keung Yeung Overview 3.1 Acromegaly 3.2 Atopic eczema 3.3 Cushing’s syndrome 3.4 Diabetic retinopathy 3.5 Erythema nodosum 3.6 Graves’ disease 3.7 Hypertensive retinopathy 3.8 Optic atrophy 3.9 Osler-Weber-Rendu syndrome (hereditary telangiectasia) 3.10 Papilloedema Examination case scenarios 21 21 24 28 31 33 36 40 40 41 43 44 47 48 49 51 52 53 54 55

Contents vii 4. Endocrinology and General—Long Cases 56 Karen Siu-Ling Lam, James D. Best, Annie Wai-Chee Kung, and Kathryn Choon-Beng Tan 4.1 Acute confusion (diabetes mellitus) 56 4.2 Galactorrhoea-amenorrhoea (prolactinoma) 58 4.3 Hypercalcaemia (primary hyperparathyroidism) 61 4.4 Unexplained weight loss (Graves’ disease) 63 GASTROENTEROLOGY AND HEPATOLOGY Man-Fung Yuen 5. Gastroenterology and Hepatology—Short Cases 66 Man-Fung Yuen, Wai-Keung Leung, and Ching-Lung Lai Overview 66 5.1 Alcoholic liver disease 69 5.2 Ascites and splenomegaly : 70 Examination case scenarios 72 6. Gastroenterology and Hepatology—Long Cases 73 Man-Fung Yuen, Wai-Keung Leung, and Ching-Lung Lai 6.1 Epigastric pain (functional dyspepsia) 73 6.2 Heartburns (gastro-oesophageal reflux disease) 71 6.3 Chronic diarrhoea (ulcerative colitis) 80 6.4 Progressive abdominal distension (hepatitis B cirrhosis with ascites) 83 6.5 Abdominal distension in a previous intravenous drug abuser (hepatitis C-related hepatocellular carcinoma) 87 6.6 Patient with primary biliary cirthosis and hepatic encephalopathy for assessment of hepatic transplantation 93 6.7 A woman with haematemesis (variceal bleeding complicating alcoholic cirrhosis) 97

viii ~ Contents HAEMATOLOGY Eric Tse 7. Haematology—Short Cases Eric Tse, Yok-Lam Kwong, and Luen-Bik To Overview 7.1 Chronic lymphocytic leukaemia 7.2 Chronic myeloid leukaemia 7.3 Haemolytic anaemia 7.4 Myelofibrosis 7.5 Lymphoma 8. Haematology—ILong Cases Eric Tse, Yok-Lam Kwong, and Luen-Bik To 8.1 A man with fever (acute leukaemia) 8.2 A woman with easy bruising (idiopathic thrombocytopenic purpura) 8.3 Bone pain with anaemia (multiple myeloma) NEPHROLOGY Daniel Tak-Mao Chan 9. Nephrology—Short Cases Sydney Chi-Wai Tang, Kar-Neng Lai, Desmond Yat-Hin Yap, Cindy Bo-Ying Choy, and Daniel Tak-Mao Chan Overview 9.1 Anti-neutrophil cytoplasmic antibodies (ANCA) positive renal vasculitis (with skin vasculitis) 9.2 Polycystic kidney disease 9.3 Transplant kidney Examination case scenarios 101 101 103 104 105 106 107 109 109 111 114 117 117 119 121 122 125

Contents 10. Nephrology—Long Cases Desmond Yat-Hin Yap, Wai-Kei Lo, Kar-Neng Lai, and Daniel Tak-Mao Chan 10.1 Malaise and nausea (chronic kidney disease) 10.2 Polydipsia and ankle swelling (diabetic nephropathy) 10.3 A young man with gross haematuria (IgA nephropathy) 10.4 A young lady with ankle swelling (lupus nephritis) 10.5 Abdominal pain and peritoneal dialysis (PD) (PD associated peritonitis) NEUROLOGY 11. Shu-Leong Ho Neurology—Short Cases Shu-Leong Ho, Raymond Tak-Fai Cheung, Windsor Mak, Kay-Cheong Teo, and Koon-Ho Chan Overview 11.1 Cerebellar syndrome 11.2 Chronic inflammatory demyelinating polyneuropathy (CIDP) 11.3 Lateral medullary syndrome 11.4 Amyotrophic lateral sclerosis (ALS) 11.5 Multiple sclerosis 11.6 Parkinson’s disease 11.7 Polymyositis/Dermatomyositis 11.8 Dysphasia 11.9 Syringomyelia (syringobulbia) Examination case scenarios ix 127 127 131 133 136 138 142 142 145 146 148 150 152 153 155 157 158 160

X 12. Contents Neurology—Long Cases Raymond Tak-Fai Cheung, Shu-Leong Ho, Windsor Mak, and Koon-Ho Chan 12.1 Confused speech (embolic stroke due to rheumatic mitral valve disease and atrial fibrillation) 12.2 Epilepsy with poor seizure control 12.3 Diplopia on reading (myasthenia gravis with thyrotoxicosis) 12.4 Tuberculous meningitis complicated by stroke RESPIRATORY MEDICINE 13. 14. Mary Sau-Man Ip and Gary Lee Respiratory Medicine—Short Cases David Chi-Leung Lam, James Chung-Man Ho, and Mary Sau-Man Ip Overview 13.1 Bronchiectasis 13.2 Chronic obstructive pulmonary disease (COPD) 13.3 Collapsed lung 13.4 Pleural effusion 13.5 Upper lobe/apical fibrosis Examination case scenarios Respiratory Medicine—Long Cases James Chung-Man Ho, Christopher Kim-Ming Hui, David Chi-Leung Lam, Kenneth Wah-Tak Tsang, Wah-Kit Lam, and Mary Sau-Man Ip 14.1 Persistent cough with dyspnoea (asthma) 14.2 Recurrent haemoptysis (bronchiectasis) 14.3 Chronic cough and weight loss (carcinoma of lung) 14.4 Breathing difficulty during sleep (obstructive sleep apnoea) 14.5 Progressive dyspnoea (pleural effusion) 164 164 167 171 174 178 178 180 183 185 187 190 191 195 195 197 201 204 208

Contents 14.6 Progressive dyspnoea and cough—idiopathic pulmonary fibrosis (IPF) 14.7 A lung cancer patient with sudden dyspnoea (pulmonary thromboembolism as a complication in lung neoplasm) RHEUMATOLOGY Chak-Sing Lau 15. Rheumatology—Short Cases Chak-Sing Lau, Carman Ho, Temy Mo-Yin Mok, and Raymond Woon-Sing Wong Overview 15.1 Dermatomyositis 15.2 Gout 15.3 Nodal osteoarthritis 15.4 Psoriatic arthritis 15.5 Scleroderma 15.6 Sjogren’s syndrome Examination case scenarios 16. Rheumatology—Long Cases Chak-Sing Lau, Carmen Ho, Temy Mo-Yin Mok, and Raymond Woon-Sing Wong 16.1 Back pain for two years (ankylosing spondylitis) 16.2 A woman with multiple problems (systemic lupus erythematous) 16.3 Recurrent right shoulder pain (theumatoid arthritis) MEDICAL ETHICS AND COMMUNICATION Cyrus Rustam Kumana and Rosie Tse-Tse Young 17. Medical Ethics and Communication Overview 17.1 A patient with haemorrhagic stroke xi 211 215 219 219 221 224 227 228 230 233 234 237 237 240 243 247 247 249

xii Contents 17.2 A lorry driver with epilepsy 17.3 Terminal cancer of the pancreas 17.4 Consent for drug trial 17.5 Emerging controversies Further reading PROFESSIONALISM 18. Joseph Kwan Medical Professionalism Joseph Kwan and Julie Chen Introduction 18.1 Case study 1: Being open and honest when something goes wrong 18.2 Case study 2: Improper disclosure on social media 18.3 Case study 3: Maintaining a professional boundary 18.4 Case study 4: Conflict of interest 18.5 Case study 5: Self-prescription Conclusion References IMAGES 19. 20. Respiratory Diagnostics David Chi-Leung Lam, Christopher Kim-Ming Hui, Jamie Chung-Mei Lam, Julie Kwan-Ling Wang, and Macy Mei-Sze Lui 19.1 CXRs and CT thorax images 19.2 Lung function tests 19.3 Sleep case studies with polysomnograms Electrocardiogram Hung-Fat Tse 250 251 253 255 258 259 259 261 262 263 265 266 267 267 269 269 285 289 295

Contents 21. Fundi Nelson Ming-Sun Wat 22. Skin Johnny Chun-Yin Chan, Chi-Keung Yeung, and Henry Hin-Lee Chan 23. Neural Images Raymond Tak-Fai Cheung 24. Plain X-ray Images Chi-Ho Lee and Chak-Sing Lau Appendix: Guidelines on Do Not Attempt CPR Decisions Cyrus Rustam Kumana List of Contributors Index Xiii 317 328 353 376 391 400 410

Foreword It is a pleasure to welcome the second edition of this special book. My comments in the foreword to the first edition apply equally here. While the contents and layout are similar, certain sections have undergone modification, and diagnostic approaches and treatment modalities have been brought up to date, in keeping with advances in medical science. There are several new authors, mostly young—it is pleasing to note. In the sections with advice to the patient, the word “prevention” often appears. The preventive aspect of patient management cannot be over emphasized. Not only can the recurrence of the illness in question be avoided, many current diseases such as those related to lifestyle, including malignancies, are essentially preventable. The physician is well placed to impress this upon patients and their families. The chapter on medical professionalism has been well rewrit- ten. But as previously pointed out, the teaching of professionalism is not easy. How does one instruct another to be compassionate? The illustrative examples given underscore the fact that the acqui- sition of professionalism comes with experience—the experience of life. It would be well for us to remember that learning from role models is time-honoured and effective.

Foreword xv The authors are to be congratulated on their ingenuity and scholarship. This book should be of value not only to those prepar- ing for examinations but as a regular reference for all. It is not a replacement for the standard textbook, but is a most useful and unique problem-based guide to diagnosis and patient management. Sir David Todd Emeritus and Honorary Professor Department of Medicine University of Hong Kong

Foreword to the First Edition There is a truism in medicine that diagnosis must precede treat- ment. How a diagnosis is arrived at depends on knowledge, experi- ence, judgement, and selected investigations. In many instances only a so-called differential diagnosis can be made. The severity of the illness and urgency to initiate treatment sometimes call for the most likely diagnosis or working diagnosis. The problem-based approach is consistent with this perception of diagnosis and treat- ment and provides a logical and rewarding methodology for the management of patients. In this book, the authors—all physicians with considerable knowledge and experience—clearly describe a problem-based approach to the management of common diseases. This has been expertly and successfully achieved. There are illustrative long and short cases preceded by an overview of the relevant subspecialty; the questions being posed and the pitfalls that are mentioned are very useful. The inclusion of images and clinical laboratory results is an additional asset. The contents are orientated towards degree or professional examinations. While the psychological and social aspects of the patient, so important in history taking and patient management, are beyond the scope of this book, they should not be forgotten. After all, clinical medicine is an art as well as a science. To some extent at least the chapters on medical ethics and comumunication, and on professionalism, compensate for this. The practical guidelines on in-hospital resuscitation decisions help to clarify an often confusing topic.

Foreword to the First Edition ~ xvii Undergraduates and physicians at all stages of their career will find this book illuminating and helpful. It provides a source of concise information and is well designed for rapid revision, for both examiners and candidates. The authors are to be congratulated on their unique and useful contribution to this relatively neglected area of the medical literature. Sir David Todd Emeritus and Honorary Professor Department of Medicine The University of Hong Kong

Preface The essence of a medical textbook is to transfer knowledge and improve clinical care. This book does not aim to be comprehensive. It is intended primarily to provide a compact aid for medical stu- dents and to help them in the preparation of examination in general medicine. The format of the book is problem-based, in line with the problem-based approach adopted by many medical schools worldwide. A broad range of common medical cases is covered. Clinical aspects, differential diagnoses, appropriate investiga- tions, and management of relevant cases in each subspecialty are presented, with particular emphasis on the applicability to exami- nation settings. Medicine is an ever changing science. Since the publication of the first edition in 2006, there have been major advances in many aspects of medicine, and new information has become available. In the swift current of scientific progress, diagnosis and disease management in many areas of clinical practice have changed. Innovations in technology have led to improvement in our diag- nostic tools, and novel therapeutic agents have been developed and incorporated into treatment algorithm. Hence, in this new edition, all the cases have been revised to keep the material up-to-date. New topics have also been added. Emerging controversies in medical ethics and how to uphold the standards of professional conduct in this era are also covered. Since we have tried to provide sufficient detail in the text to help in the diagnosis and treatment of common medical conditions, we hope this book will also prove

Preface xix useful to our junior doctors in their day-to-day practice and help them to refresh their memories of the diagnostic possibilities in the cases they encounter. It should also be helpful in their preparation of case presentation. We hope this new edition will serve the needs of our readers and will be worthy of their frequent use. We thank the many con- tributors who have poured their knowledge into this volume, and any suggestions for improvement will be warmly welcomed and carefully considered. Rosie Young and Kathryn Tan Department of Medicine University of Hong Kong 2016