Case studies from Professor John Murtagh

Learn from the master! Professor John Murtagh's distributes regular case studies to
GPRA members through our e-newsletter. Drawn from his over 30 years experience as a general practitioner, Professor Murtagh provides engaging, authentic cases in clinical practice, providing valuable insight and noting the common mistakes and problems that GPs can encounter.

Read a selection of past case studies:

A 6 year old boy with knee pain and a limp

Charlie is a very healthy and active six year old schoolboy who is brought to the surgery by his mother because she is concerned and puzzled by his complaint of right knee pain. He says that he has had a sore knee on and off for two to three days and has developed a noticeable limp. His mother could not find any soreness or other signs on the knee. 

She said that there is no history of an injury although he has been playing football recently. About two weeks ago he did have a mild upper respiratory infection.

On examination the child looked well, 50th centile for height and weight with normal vital signs including his temperature. Examination of the knee was normal with no localised tenderness and a normal range of active and passive movements. However examination of his right hip revealed limitation of internal rotation, abduction and extension. Charlie complained of knee pain during these movements especially passive movements.

Diagnosis: irritable hip due to transient synovitis related to a preceding viral infection. Plain X ray was normal but ultrasound showed fluid in the hip joint. He was treated with bed rest and ibuprofen and settled to normality in 7 days. A follow up X-ray was arranged in 6 months to exclude Perthes disease.

Practice point: remember that pathology in the hip can present with ipsilateral knee pain.

Puzzling lower cyclic abdominal pain in a 13 year old girl

Amy, a 13 year schoolgirl, presented with a five-month history of suprapubic discomfort. The pain was mild at first and after two episodes, about one month apart, her parents took her to a hospital. She was examined and no abnormality was found and the family was reassured that it was some form of colic of the lower gut. The lower abdomino-pelvic pain eventually returned and was more intense. It was now accompanied by mild constipation and low back pain. Basic investigations which included a full blood examination, urine-analysis and a plain X-ray were reported as normal. She was prescribed a laxative to make her bowels more regular. The pain settled again for about 3 weeks but on recurrence she saw another doctor who ordered ultrasound imaging of her lower abdomen. It did not reveal any abnormality. At the fifth visit to a private general practitioner for worse pain she complained of some difficulty with urination and felt that emptying of her bladder was incomplete. Physical examination now revealed mild distension of the suprapubic area and a palpable mass up to 3 cm above the symphysis pubis.

Diagnosis: The doctor took an appropriate genitourinary history and found that Amy had not commenced menstruation. On inspection of her external genitalia there was a distinct tense bluish bulging membrane presenting at the introitus-compatible with vaginal distension from menses caused by an imperforate hymen. A further ultrasound indicated a distended vagina and enlarged uterus. A cruciate incision was made in the hymen and 300ml of blood was drained.

A dangerous case of post-flu fatigue

Melinda, a 17 year old student, attended because she was feeling weak in her arms, especially in the right arm and wrist where she described a tingling sensation that had been present for the past 24 hours. Her recent history was that of a febrile illness ‘rather like the flu’ a few days beforehand and then she unwisely played several games of tennis in a tournament that finished the previous day. She eventually had to withdraw.
Melinda also complained of headache, nausea and an aching jaw as well as the right arm weakness. Sensation to touch was normal and her reflexes were equivocal. I attributed the problem to soreness following sporting overload after a viral infection.  Notwithstanding her age I considered the possibly of carpal tunnel syndrome.

Upon planned review two days later I noticed a dramatic and disturbing change. She walked with considerable difficulty into the surgery looking well but was weak in all limbs with obvious motor weakness and loss of reflexes. She was also having breathing difficulty and her peak flow was markedly reduced.

Diagnosis: She was in fact suffering from Guillain-Barre syndrome (acute idiopathic demyelinating polyneuropathy). She was admitted to hospital where she eventually received assisted ventilation for a few days without developing complete paralysis.

Torsion of the testis — a potential disaster

Greg N, aged 15, presented with one hour of the sudden onset of severe suprapubic and right groin pain with associated vomiting. On examination the right testicle was tender, red and swollen. Its elevation increased the pain His GP referred him to the nearest surgeon and asked him to attend to it urgently. However he was placed at the end of the operating list and when operated on 8 hours from the onset of the pain an orchidectomy was performed because the testicle was infarcted and necrotic. The surgeon has mismanaged the case of Greg.

One of the classic challenges facing the general practitioner is the early diagnosis and quick referral of a testicular torsion. The loss of a testicle, an avoidable problem, is a real “time bomb”. Apart from the distress for the patient and his family, the legal consequences are terrible for the practitioner. It is an all too common cause of litigation.

The time factor: The optimal time to operate for torsion of the testis is within 4 to 6 hours from the onset of the pain. About 85% of torsive testes are salvageable within 6 hours but by 10 hours the salvage rate has dropped to 20%1,2  At surgery the testicle is untwisted and an orchidopexy (anchoring the testicle) is performed. A gangrenous testicle is removed.

Cautionary tales: Many testicles are lost because of inappropriate delays with referring for an ultrasound. The patient should be referred immediately to a surgeon or surgical centre. Teenage boys presenting with acute right iliac fossa pain, nausea and vomiting are sometimes misdiagnosed as acute appendicitis.

References.

1. Bird S. Medicolegal handbook for general practice. Melbourne: RACGP. 2006; 52-3
2. Wijesinha SS. Torsion of the testis. Update 19 February 1997; 218