100 Cases in Clinical Pathology and Laboratory Medicine -
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Second Edition
100 in Clinical
Pathology and
CASES Laboratory
Medicine
Eamon Shamil MBBS, MRes, DOHNS, FRCS (ORL-HNS)
PPost-CCT
John Rees MD
Fellow in FRCP
Rhinology, Anterior Skull Base, and
Professor of Medical
Facial Plastic SurgeryEducation,
King’s College
The Royal London
National ENT School of Medicine at Guy’s,
Hospital,
King’s andCollege
University St Thomas’ Hospitals,
London London,
Hospitals NHS UK
Foundation Trust, UK
James Pattison DM FRCP
Praful RaviNephrologist,
Consultant MA, MB, BChir, MRCP
Guy’s and Physician
Attending St Thomas’inNHS FoundationOncology,
Genitourinary Trust,
London, UK Cancer Institute; Instructor of Medicine,
Dana-Farber
Harvard Medical
Christopher School,
Kosky MDBoston,
FRCP Massachusetts, USA
Ashish Chandra
Consultant Physician,
FRCPath, DipRCPath (Cytol)
General and Respiratory
Lead Consultant Medicine &
for Cytopathology & Urological
Sleep Disorders,
Guy’s and St Thomas’ NHS Foundation
Histopathology, Guy’s and St Thomas’ NHS Trust;
Foundation
Honorary
Trust, London, UK; Chair, British Association London,
Senior Lecturer, King’s College UK
of Urological
Pathologists (BAUP); Vice President, International Academy
of Cytology (IAC); Deputy Editor, Cytopathology
100 Cases Series Editor:
Janice
100 Cases Rymer MD FRCOG FRANCOG FHEA
Series Editor:
Janice Rymer MBBS, FRACP
Dean of Undergraduate Medicine and Professor of
Gynaecology,
Professor of Obstetrics & Gynaecology and Dean
King’s College
of Student London
Affairs, King’sSchool of Medicine,
College London, UK
London School
of Medicine, London, UK
BocaRaton
Boca Raton London
London New
NewYork
York
CRCPress
CRC Pressisisan
animprint
imprintofofthe
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Taylor&&Francis
Taylor FrancisGroup,
Group,an informabusiness
aninforma business
Second edition published 2023
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487–2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2023 Eamon Shamil, Praful Ravi and Ashish Chandra
First edition published by CRC Press 2014
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made
to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for
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Library of Congress Cataloging-in-Publication Data
Names: Shamil, Eamon, editor. | Ravi, Praful, editor. | Chandra, Ashish (Histopathologist) editor. |
Shamil, Eamon. 100 cases in clinical pathology.
Title: 100 cases in clinical pathology and laboratory medicine / edited by Eamon Shamil, Praful Ravi, Ashish Chandra.
Other titles: One hundred cases in clinical pathology and laboratory medicine | 100 cases
Description: Second edition. | Boca Raton : CRC Press, 2023. | Series: 100 cases | Preceded by 100 cases in clinical
pathology / Eamon Shamil, Praful Ravi, Ashish Chandra. c2014. | Includes bibliographical references and index. |
Summary: “100 Cases in Clinical Pathology and Laboratory Medicine presents 100 clinical scenarios commonly
seen by medical students and junior doctors in the emergency department, outpatient clinic, operating theatre or in
general practice. A succinct summary of the patient’s history, examination and initial investigations is followed by
questions on each case, with particular emphasis on the interpretation of the results and in which an understanding
of the underlying clinical pathology is central to arriving at the correct diagnosis. The answer includes a detailed
discussion on each topic, providing an essential revision aid as well as a practical guide for students and junior
doctors, especially those preparing for undergraduate and postgraduate examinations. Making speedy and
appropriate clinical decisions, and choosing the best course of action to take as a result, is one of the most important
and challenging parts of training to become a doctor. Fully revised and updated for this second edition, these
true-to-life cases will teach students and junior doctors to recognize important clinical conditions, to request the
appropriate pathological investigation and correctly interpret those results, and, as a result, to develop their
diagnostic and management skills”— Provided by publisher.
Identifiers: LCCN 2022032063 (print) | LCCN 2022032064 (ebook) | ISBN 9781032151397 (hardback) |
ISBN 9781032151373 (paperback) | ISBN 9781003242697 (ebook)
Subjects: MESH: Pathologic Processes | Signs and Symptoms | Clinical Laboratory Techniques | Problems and
Exercises | Case Reports
Classification: LCC RC69 (print) | LCC RC69 (ebook) | NLM QZ 18.2 | DDC 616/.047—dc23/eng/20220914
LC record available at https://lccn.loc.gov/2022032063
LC ebook record available at https://lccn.loc.gov/2022032064
ISBN: 9781032151397 (hbk)
ISBN: 9781032151373 (pbk)
ISBN: 9781003242697 (ebk)
DOI: 10.1201/9781003242697
Typeset in Baskerville
by Apex CoVantage, LLC
Access the Support Material: www.routledge.com/9781032151373
To my parents, siblings and mentors, who taught me the
importance of kindness, compassion and integrity
Eamon Shamil
To my parents and my teachers
Praful Ravi
To my mother, my first teacher
Ashish Chandra
CONTENTS
Preface xi
Acknowledgements xiii
Contributors xiii
Reference Ranges xv
Section 1: Laboratory Medicine: Chemical Pathology,
Immunology and Genetics
Case 1 Polyuria and Polydipsia 3
Case 2 Traces of Blood Found on Urine Dipstick 7
Case 3 Confusion, Lethargy and Shortness of Breath 9
Case 4 A Child with Facial Swelling 11
Case 5 Joint Pains and Fatigue 13
Case 6 Anxiety, Irritability and Reduced Menstrual Frequency 15
Case 7 Screening for Prostate Cancer 17
Case 8 A Young Woman Is Found Unconscious in Bed 19
Case 9 A Middle-aged Woman with Jaundice 23
Case 10 Drug Overdose 27
Case 11 Fatigue, Weakness and Constipation 29
Case 12 Excessive Hair Growth and Infertility 31
Case 13 Fatigue and Irregular Periods 35
Case 14 Stiff and Painful Hands 37
Case 15 Abdominal Pain, Nausea and Vomiting 41
Case 16 Frequent Throat and Chest Infections 47
Case 17 A Routine ‘Health Check’ for a 55-Year-Old Man 49
Case 18 Collapse in a Patient Undergoing Chemotherapy 53
Case 19 A 10-Day-Old Baby with Ambiguous Genitalia 57
Case 20 Fatigue, Weakness and Weight Gain 61
Case 21 Hypertension in a Young Woman 63
Case 22 Nausea, Vomiting, Weakness and Paraesthesia 65
Case 23 Erectile Dysfunction in a Young Man 67
Case 24 A Young Man with ‘High Cholesterol’ 69
Case 25 Rash after a Bone Marrow Transplant 71
Case 26 A Fall on an Outstretched Hand 73
Case 27 A Patient in Follow-up after a Liver Transplant 75
Case 28 A Man with Poorly Controlled Blood Pressure 79
Case 29 Dizziness on Standing Upright 83
vii
viii Contents
Case 30 Sudden-onset Chest Pain in a Tall Woman 85
Case 31 Concerns about the Risk of Breast Cancer 87
Case 32 Seizure in a Neonate 89
Section 2: Histopathology
Case 33 A Young Woman with Ankle Swelling and Shortness of Breath 93
Case 34 Chest Pain and Sudden Death 95
Case 35 An Elderly Man with Severe Back Pain 97
Case 36 Increased Breathlessness and Sudden Death 99
Case 37 A Worsening Cough and Haemoptysis 101
Case 38 A Young Man with Shortness of Breath and Haemoptysis 105
Case 39 Sudden-onset Weakness and Dysphasia 107
Case 40 Numbness, Weakness and Clumsiness 111
Case 41 Forgetfulness and Disorientation 113
Case 42 Coffee-ground Vomiting 115
Case 43 Episodic Right Upper Quadrant Abdominal Pain 117
Case 44 Chronic Diarrhoea and Flatulence 119
Case 45 A Young Man with Bloody Diarrhoea 121
Case 46 Abdominal Discomfort and Generalised Weakness 125
Case 47 Abdominal Pain in a Publican 127
Case 48 Abdominal Distension, Loss of Appetite and Malaise 129
Case 49 Back Pain and Fever in a Diabetic 131
Case 50 Urinary Problems in an Elderly Man 133
Case 51 A Young Man with a Testicular Lump 135
Case 52 Heavy and Painful Menstrual Bleeding 139
Case 53 Abnormal Vaginal Bleeding 141
Case 54 A Lump in the Breast 143
Case 55 Lymph Node Enlargement in a Young Man 145
Case 56 An Itchy, Bleeding Mole on the Back 149
Case 57 Blood in the Urine of an Elderly Man 151
Case 58 Thyroid Disease in a Young Woman 153
Section 3: Haematology
Case 59 Shortness of Breath and Heartburn 157
Case 60 Raised White Cell Count in an Asymptomatic Individual 161
Case 61 Worsening Fatigue and Bleeding Gums 165
Case 62 Burning Urine and an Abnormal Clotting Screen 169
Case 63 Headaches, Blurred Vision and Itching 171
Case 64 A Painful Arm and a Large Spleen 175
Contents ix
Case 65 A Rash on the Thighs 179
Case 66 Fatigue and Weight Loss 183
Case 67 Pneumonia with Abnormal Liver Function 187
Case 68 Recurrent Epistaxis 193
Case 69 Bruising after a Pneumonia 197
Case 70 Headache and a Rash 201
Case 71 Shortness of Breath and Weight Loss 205
Case 72 Anaemia Resistant to a Blood Transfusion 207
Case 73 Asymptomatic Anaemia in the Elderly 211
Case 74 Back Pain and Fatigue 217
Case 75 Short of Breath and Underweight 221
Case 76 Deterioration after a Blood Transfusion 225
Case 77 Headache and Blurred Vision 229
Case 78 Lower Back Pain 231
Section 4: Microbiology
Case 79 Flu-like Illness after Foreign Travel 235
Case 80 Leg Pain and Fevers 239
Case 81 Fever and Collapse 243
Case 82 Burning Sensation When Passing Urine 249
Case 83 A Bit Short of Breath 253
Case 84 Unhappy Camper 257
Case 85 Diarrhoea in an Elderly Man 261
Case 86 A Painful Knee 265
Case 87 A Pain in the Ear 269
Case 88 A Red Eye 271
Case 89 Child with a Rash 275
Case 90 Pelvic Pain 281
Case 91 A Painful, Swollen Jaw 285
Case 92 Traveller’s Diarrhoea 291
Case 93 Fever in a Returning Traveller 295
Case 94 A Spot of Confusion 299
Case 95 Congenital Infection 303
Case 96 A Chronic Cough 307
Case 97 A Jaundiced View 311
Case 98 Gram-negative Bacteraemia 315
Case 99 A Groin Swelling 319
Case 100 Urethral Discharge 323
Index 327
PREFACE
We are pleased to present a second edition of this textbook, having received excellent feed
back on the first edition, which was published in 2014. We have revised the cases and included
new ones to reflect the updated medical student curriculum. We have also updated the name
of the textbook to include Laboratory Medicine, reflecting content that explains how to inter
pret and manage abnormal blood tests.
Our aim remains the same: to improve the understanding of the underlying pathology of
both common and rare (but important) conditions. We explain how the underlying pathology
is related to symptoms, investigations, and management of patients, giving the reader a useful
overview of the topic, as well as preparing them for undergraduate and postgraduate exams.
An appreciation for “how does this disease process occur” will help students and doctors
provide better care to their patients and drive enthusiasm to improve care.
Eamon Shamil
Praful Ravi
Ashish Chandra
xi
ACKNOWLEDGEMENTS
The specimen images are from the Gordon Museum of Pathology, King’s College London.
CONTRIBUTORS
Dr Mark Ong BSc, MBChB, MRCS
Consultant Histopathologist
Guy’s & St Thomas’ NHS Foundation Trust
London, UK
Dr Alexander Polson FRCPath
Consultant Histopathologist
Guy’s & St Thomas’ NHS Foundation Trust
London, UK
Dr Caryn Rosmarin MBBCh, DTM&H, MSc (Med Micro), FCPath (SA), FRCPath
Microbiology/Infection Control Consultant
Microbiology Training Programme Director (NE London)
Barts Health NHS Trust
London, UK
Dr Simran Goyal BA, MBBCh
Foundation Doctor
School of Clinical Medicine
University of Cambridge, UK
Dr Hassen al-Sader MBBS, MRCP
Haematology Consultant
West Hertfordshire Teaching Hospitals NHS Trust
Honorary Consultant, Lymphoma Team, University College London Hospital, UK
Dr Wael Faroug Elamin MBBS, BSc, MSc, MD, FRCPath, FRCP.
Medical Director, G42 Healthcare,UAE;
Honorary Senior Lecturer, QMUL;
Consultant Clinical Microbiologist, Elrazi University, Sudan
xiii
REFERENCE RANGES
HAEMATOLOGY
Haemoglobin (Hb) 11.4–15.0 g/dL
White cells (WCC) 3.9–10.6 g/dL
Neutrophils 2.0–7.5 × 10 9/L
Lymphocytes 1.3–3.5 × 10 9/L
Eosinophils <0.4 × 10 9/L
Platelets (PLT) 150–440 × 10 9/L
Reticulocytes 0.5–1.5%
Mean cell volume (MCV) 77–95 fL
Mean cell haemoglobin (MCH) 27.0–32.0 pg
Serum iron 14–31 mmol/L
Serum ferritin 20–300 mg/L
Total iron binding capacity (TIBC) 45–80 μmol/L
Transferrin saturation 20–50%
BIOCHEMISTRY
Sodium (Na) 135–145 mmol/L
Potassium (K) 3.5–5 mmol/L
Urea (Ur) 2.5–7.8 mmol/L
Creatinine (Cr) 60–110 μmol/L
Fasting glucose (Gluc) 3.5–6 mmol/L
Bilirubin (Bili) <21 μmol/L
Alanine aminotransferase (ALT) 10–40 IU/L
Aspartate aminotransferase (AST) 11–60 IU/L
Alkaline phosphatase (ALP) 20–140 IU/L
Gamma glutamyl transferase (GGT) <65 IU/L
Serum protein 60–80 g/L
Albumin (Alb) 35–50 g/L
Corrected calcium (corr Ca) 2.1–2.6 mmol/L
Phosphate (PO4) 0.81–1.45 mmol/L
Parathyroid hormone (PTH) 1.2–5.8 pmol/L
Prolactin (non-pregnant) <20 ng/mL
Serum osmolality 278–305 mOsm/kg
Lactate dehydrogenase (LDH) 240–480 IU/L
IgG 6.5–16.0 g/L
IgA 0.4–3.5 g/L
IgM 0.55–3.0 g/L
C-reactive protein (CRP) <5 mg/L
Erythrocyte sedimentation rate (ESR) <30 mm/hr
Thyroid-stimulating hormone (TSH) 0.5–5 mU/L
Total T4 58–174 nmol/L
Free T4 10–23 pmol/L
Free T3 3.5–6.5 pmol/L
xv
xvi Reference Ranges
Amylase 60–180 U/L
Cholesterol <5 mmol/L
LDL cholesterol <3 mmol/L
HDL cholesterol >1 mmol/L
Triglyceride <2.26 mmol/L
COAGULATION
International normalised ratio (INR) 0.9–1.2 sec
Prothrombin time (PT) 11–15 sec
Activated partial thromboplastin time (APTT) 18–28 sec
Fibrinogen 1.5–3.0 g/L
D-Dimer <250 μg/L
URINE
Urine osmolality 50–1200 mOsm/kg
Urine pH 6.5–8
BLOOD GASES
pH 7.35–7.45
pO2 11.3–12.6 kPa
pCO2 4.5–6 kPa
HCO3 –22 to 26 mmol/L
Base excess –2 to 2 mmol/L
