Clinical medicine (London, England)
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Patients presenting with symptoms suggestive of functional disorder are very frequent in practice. While it is always necessary to exclude treatable organic pathology, there are important clues in the presentation that can help the clinician. ⋯ Because full assessment of functional symptoms takes time, it is suggested that a clinical support nurse with some training in psychological management should be available to guide the management of the patients with these disorders. Such support nurses, based in the clinic, offer a seamless way of providing care that is not achieved by external referral to psychologists or equivalent staff.
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Hypercalcaemia is a common electrolyte abnormality with 90% of cases due to either primary hyperparathyroidism or malignancy. Other causes of hypercalcaemia often require careful consideration. ⋯ This approach is illustrated by a case which posed a diagnostic challenge: a patient with significant hypercalcaemia due to acute atypical isolated sarcoid myositis. This case highlights an under-recognised clinical syndrome with distinct biochemical and radiological findings.
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Percutaneous endoscopic gastrostomy (PEG) provides long-term nutritional support to those unable to tolerate intake orally. The benefits of a PEG depend on the indication and the individual, and are considered when it has the potential to improve mortality, nutritional status or quality of life. Often, family members and healthcare professionals have to act on behalf of the patient. ⋯ This may result in unnecessary PEG placement. For certain indications (dementia for example), there is limited evidence of any benefits a PEG may give and may actually cause harm. Guidance to improve patient selection and increase education for healthcare professionals is essential in achieving the best outcome for the patient.
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Normal baseline investigation results in a patient with common symptoms is often labelled as being due to a functional disorder, with all the pejorative connotations that go along with that term. When given the opportunity to see a patient for a second opinion, it is important to retain an open mind rather than assuming previous assessments are correct. Such an attitude helps with both attaining the definitive diagnosis but is also crucial to helping give hope to the patient. Understanding the patient's concerns about the meaning of their symptoms is critical in finding the balance between advanced investigation to identify a putative cause versus a decision to proceed with symptomatic control.