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حالات سريرية


ما التدبير ؟ |

حالة سريرية

الوصف الكامل Background

سيدة 65 سنة لديها قرحة عفجية مشخصة وتخضع للمعالجة بالحمية الغذائية و حاصرات H2 , قبلت المريضة بنزف هضمي علوي حاد , ما الخطوة التالية بالتدبير بعد البدء بتعويض الدم ؟
1- اعطاء البيزموت و التتراسكلين والميترونيدازول
2- اعطاء اومبيرازول
3- تنظير هضمي علوي و تخثير الوعاء النازف
4- فتح البواب جراحيا و ربط الوعاء النازف


كتلة بعد استئصال كولون تام ؟ |

حالة سريرية

الوصف الكامل Background

فتاة 18 سنة خضعت لاستئصال كولون تام بسبب داء البوليبات الغدية الكولونية العائلية . بعد سنتين من الجراحة شوهدت كتلة لا عرضية 4 سم بجدار البطن مكان الشق الجراحي , ما التدبير الملائم؟
1- شوط من الستيروئدات ومثبطات المناعة
2- شوط من مثبطات المناعة
3- تطبيق علاج شعاعي
4- الاستئصال الواسع للكتلة
5- لا علاج .


ابتعلاع أجسام ممغنطة |

حالة سريرية

الوصف الكامل Background


A 9-year-old boy ingested 23 magnets (Panel A). Four days later, he had clinical and surgical evidence of intestinal perforation and peritonitis due to pressure necrosis of the bowel. In an unrelated incident, a developmentally delayed 13-year-old boy ingested 15 magnets. Ten days later, volvulus and intestinal occlusion developed (Panel B, arrows). Both patients were operated on without complications, and all magnets were removed. Although ingested nonmagnetic foreign bodies are likely to be passed spontaneously without consequence, ingested magnets may attract each other through the intestinal wall and cause severe damage, such as pressure necrosis, perforation, intestinal fistulas, volvulus, and obstruction.

طفل بعمر 9 سنوات ابتلع 23 مغناطيساً (وهو ما يظهر في الإطار A من الصورة) . وبعد أربعة أيام بدأت تظهر لديه أعراض سريرية جراحية لانثقاب الأمعاء والبريتوان بسبب حدوث التنخر المواتي للأمعاء.
وفي حالة أخرى منفصلة , ابتلع طفل بعمر 13 سنة 15 مغاطيساً . وبعد عشرة أيام من ذلك حدث انفتال في الأمعاء وانسداد ( وهو ما يظهر في الإطاء B من الصورة ) .

كلا المريضين تم تدبيرهما من دون أي اختلاطات , وتم إزالة كافة المغناطيسات .

على الرغم من أن ابتلاع أجسام غير مغناطيسية يحدث على الأرجح دون خطورة كبيرة , فبالمقابل تقوم الأجسام المغناطيسية باالانجذاب لبعضها عبر جدران الأمعاء مسببةأذية منتشرة ( كالانضغاط المواتي ,أو الانثقاب , أو النواسير المعوية , أوالانفتال المعوي , أو انسداد الأمعاء .

منقول ومترجم من : The New England Journal of Medicine (NEJM)]


Waht is this procedure? |

حالة سريرية

الوصف الكامل Background

Can you tell what is being done in this procedure and what is patient diagnosis?


ما الخطوة التالية في هذا النزف الهضمي؟ |

حالة سريرية

الوصف الكامل Background
A 63-year-old man in apparent good health is convinced by magazine articles and TV programs that he will live longer if he takes one aspirin tablet every day. After about 3 weeks of doing so (325 mg/day), he begins to notice bright red blood in the toilet paper when he wipes after a bowel movement. This does not occur every time, but only when, for whatever reason, he has to strain more than usual. He has never had any discomfort referable to hemorrhoids, or any bowel pathology that he is aware of. Anoscopy and digital rectal examination show external and internal hemorrhoids, none of which are bleeding at the time of the examination. Which of the following is the most appropriate next step in management?

A.Discontinue the aspirin
B.Perform rubber-band ligation of the internal hemorrhoids
C.Perform 60-cm flexible proctosigmoidoscopy
D.Recommend stool softeners
E.Reduce the aspirin dosage


رجل يشتكي من سعال وحمى وألم بالبطن. |

حالة سريرية

الوصف الكامل Background
A man in Louisiana develops coughing, fever, and abdominal pain. His doctor orders a series of X-rays, which show pulmonary infiltrates characteristic of pneumonia as well as intestinal images consistent with obstruction. On CBC, the patient has increased eosinophils. The doctor examines a stool sample from the patient and discovers microscopic oval eggs with rough surface.

رجل من لويسيانا (ولاية في أمريكا) يشتكي من سعال ،حمى ،وألم بالبطن.
طلب طبيبه سلسلة من فحوص الأشعة السينية والتي أظهرت ارتشاح رئوي يتظاهر بذات رئة، كما أظهرت صور الأمعاء انسداد فيها.
في تعداد كريات الدم ظهر هنالك زيادة في الحمضات.
فحص الطبيب البراز فأظهر بيوضاً مجهرية بيضوية الشكل ذو سطح خشن.
ما هو العامل المسبب؟


تشمع كبد |

حالة سريرية

كتابة حرة وطرح موضوع النقاش!

عامل بمطعم 58 سنة بدأ فجأة بتقيأ دموي وفقد وعيه واسعف للمشفى . بالفحص لديه علامات صدمة شديدة وتم جس الفص الأيمن للكبد بمقدار ثلاث اصابع تحت الحافة الضلعية وشوهدت عدة أوردة سطحية حول السرة متضخمة .
بسوابقه تقيأ دموي خلال الاشهر الثلاث السابقة وادمان كحول ووضع تشخيص تشمع كبدي تالي لاستعمال كحول مزمن .
يمكن تفسير الاعراض والعلامات لديه بكل مما يلي ما عدا ؟
1- يتعطل الجريان الدموي الطبيعي البابي عبر الكبد بالتشمع الكبدي
2- تصبح التفاغرات البابية الجهازية متضخمة بهذه الحالة
3- يتفاغر عند النهاية السفلية للمري فرع من وريد المعدي الأيمن مع الرافد المريئي لوريد الفرد
4- تسبب تمزق دوالي المري نزف شديد مؤدية للتقيأ الدموي
عند ارتفاع التوتر البابي تحتقن الاوردة جانب السرة الواصلة بين الأوردة السطحية للجلد (أوردة جهازية) ووريد الباب وتصبح ظاهرة


Life is never easy |

حالة سريرية

الوصف الكامل Background
Here is a case for discussion. This is not a cse taken from exams books or a case that I made up from my mind to fit a certain diagnosis. This a true life case that I am still suffering with.

A 41 y old female presented to neurology with loss of consiousness (LOC) and ? seizure activity : after neuro work up including MRI brain she was found to has only Hb 4.9 with everything else normal. She did mention vomiting after she woke up from the attack of LOC associated with mild epigastric pain . That lasted for few minutes and then resolved.
She denies black tarry stool, hematochezia , hematemisis, heartburn, change in bowel habits, weight changes or any other symptoms except fatigue and dizziness.No previous medical problem , No surgeries, No smoking or alcohol . No medications either. She works as a maid
Her exam is remarkable for pallor but otherwise normal. By the time I saw her she was already transfused 2 units of blood and her Hb was up to 8. She was already tested for Iron indeces that showed significant Fe deficiency (Fe sat % was 5% - normal 20-30%)
SO what is the next step?


hepatology case2 |

حالة سريرية

الوصف الكامل Background
A 42-year-old non-alcoholic female comes to the clinic for a follow-up of her diabetes. You decide to do her full body check-up and find out that she has an alkaline phosphatase level of 140 IU/L; AST 110 IU/L; ALT 80 IU/L; GGT 350 IU/L; total bilirubin 1.0 mg/dl; albumin 4.0 mg/dl and PT 12sec. Tests for autoimmune antibodies and viral serologies are negative. She has been obese since childhood. Her liver biopsy shows steatosis, polymorphonuclear cellular infiltrates, and necrosis. What is the most likely diagnosis in this patient?

A.Non-alcoholic hepatic steatosis (NASH).
B.Fatty liver.
C.Primary biliary cirrhosis.
D.Autoimmune hepatitis.
E.Granulomatous hepatitis.


Hepatology case |

حالة سريرية

الوصف الكامل Background
A 42-year-old African-American male presents to emergency room with severe right upper quadrant abdominal pain and abdominal distention. He has no past medical illnesses and takes no medication. On examination he has icteric sclera, tender hepatomegaly, splenomegaly and free fluid in abdomen. His laboratory report shows total bilirubin: 4.5 mg/dl, Hemoglobin: 17 g/dl, and Hematocrit: 50. CT scan shows prominent caudate lobe of liver. His liver biopsy shows centrilobular congestion. What is the most likely diagnosis in this patient?

A.Portal vein thrombosis.
.B.Right ventricular failure.
C.Veno occlusive disease.
D.Constrictive pericarditis.
E.Budd Chiari syndrome.

nice case for a 28 year old male |

حالة سريرية

الشكوى الرئيسية CC

fever / abdominal pain / constipation / rt chest pain

القصة المرضية HPI

pt suffered from fever , constipation , & abdominal pain before 2 weeks . no vomiting

he was given antibiotics by a private doctor , improved for 3 days , fever recurred , with increased rt hypochondrial pain , white productive cough and right lower chest pain. He was given again antibiotics but didnt improve .

السوابق المرضية الشخصية PMH

pt brought along an old xray with pneumoperitoneum and stated a hx of suturing a perforated duodenal ulcer of 2.5 cm in the first part of duodenum

الفحص السريري Clinical Exam

pt looks ill , toxic .
abdomen : tender , distended with absent bowel sounds , +ve puddle sign indicating ascites
chest : bilaterally dull on percussion , decreased air entry and decreased expansion on rt side

CVS , Head, neck , MSS : NAD

الاستقصاءات Investigations


CBC
was normal except for high leucocytic count ( neutrophils ), hypoalbuminemia


LFT
: elevated AST , ALT , and slight elevation in ALP


RFT
: creatinie ( 182 umol/L ) and BUN ( 16.5 mmol/L ) were elevated --- diagnosed with renal impairment


CXR
: reveald rt lower lobe pneumonia and bilateral pleural effusion


peritoneal fluid aspiration
:
Glucose body fluids : 0.10 mmol/L
Total protein body fluids : 10 g/L
fluid LDH : 4325 IU/L
( i wonder why didnt they do SAAG )


Pleural fluids
:
Glucose body fluids : 0.60 mmol/L
total protein fluids : 2.11 g/L
Fluid LDH : 3737 IU/L

pt refused to give a liver biopsy but US revealed liver nodularity

كتابة حرة وطرح موضوع النقاش!

pt was diagnosed with :
1. rt lower lobe pneumonia
2. bilateral pleural effusion ( hepatic hydrothorax)
3. hepatic cirrhosis
4. renal impairment


A 54-year-old male presents with 1 month of diarrhea |

حالة سريرية

الوصف الكامل Background
A 54-year-old male presents with 1 month of diarrhea. He states that he has 8 to 10 loose bowel movements a day. He has lost 8 lb during this time. Vital signs and physical examination are normal. Serum laboratory studies are normal. A 24-h stool collection reveals 500 g of stool with a measured stool osmolality of 200 mosmol/L and a calculated stool osmolarity of 210 mosmol/L. Based on these findings, what is the most likely cause of this patient's diarrhea?

A. Celiac sprue
B. Chronic pancreatitis
C. Lactase deficiency
D. Vasoactive intestinal peptide tumor
E. Whipple's disease

explain ur answer...


هضمية 2 |

حالة سريرية

الوصف الكامل Background

A 45-year-old male presents with a history of crushing nonradiating chest pain. Electrocardiography and exercise stress testing reveal no evidence of cardiac edema. A more detailed history is taken, and the patient states that he has had a sensation of sticking after swallowing. He notes this sensation equally whether he is eating solids or liquids. The diagnosis that is most likely to account for these symptoms is

A. achalasia
B. diffuse esophageal spasm
C. lower esophageal (Schatzki) ring
D. esophageal carcinoma
E. Zenker's diverticulum
explain your answer...


رابعة : حالة هضمية 1 |

حالة سريرية

الوصف الكامل Background

A 24-year-old patient who is known to be infected with HIV-1 presents with a 2-week history of intermittent bloody diarrhea, urgency, abdominal pain, and malaise. Stool culture for enteropathogenic organisms is negative, and analysis for ova and parasites is similarly unrevealing. The patient is taking no medication. The diarrheal symptoms do not respond to a course of ciprofloxacin. Colonoscopic examination reveals multiple areas of ulceration and mucosal erosion. Biopsy reveals the presence of cells containing a large, densely staining nucleus and abundant intracytoplasmic inclusions. The most appropriate therapy for this patient is

A. acyclovir
B. clarithromycin
C. ganciclovir
D. pentamidine
E. pyrimethamine

explain your answer....


مريضة تعاني من تعب مترق A female patient complaining of progressive fatigue |

حالة سريرية

الوصف الكامل Background
A 42-year-old woman has a 1-year history of progressive fatigue without dyspnea, chest pain, or other systemic symptoms. She sleeps well at night and does not have features of sleep apnea. The patient has hypothyroidism, managed with levothyroxine, and dysmenorrhea, treated with an estrogen/progesterone combination.

On physical examination, the thyroid is slightly enlarged but nontender. Xanthomas are present on the extensor surfaces. Abdominal examination discloses mild hepatomegaly.

Laboratory Studies
Complete blood count: Normal
Serum thyroid-stimulating hormone: Normal
Serum aspartate aminotransferase: 25 U/L (Normal: 0-35)
Serum alanine aminotransferase: 32 U/L (Normal: 0-35)
Serum alkaline phosphatase: 278 U/L (Normal: 36-92)
Serum total bilirubin : 1.1 mg/dL (Normal: 0.3-1.2)

سيدة عمرها 42 عاما لديها قصة سنة من التعب المترقي دون زلة تنفسية أو ألم صدري أو أي عرض جهازي آخر. تستطيع السيدة النوم جيدا أثناء الليل وليس لديها انقطاع نفس أثناء النوم. المريضة تعاني من قصور درق معالج بالـlevothyroxine، ولديها أيضا عسر طمث معالج باستخدام مركبات استروجين\بروجيستيرون.

بالفحص السريري: الدرق متضخمة قليلاً دون إيلام. يوجد أورام صفراوية على الأسطح الباسطة. فحص البطن كشف عن ضخامة كبدية خفيفة.

الدراسات المخبرية:
تعداد دم كامل: طبيعي
TSH المصل: طبيعي
ٍِِAST المصل: 25 وحدة\لتر (الطبيعي: 0-35)
ALT المصل: 32 وحدة\لتر (الطبيعي: 0-35)
ALP المصل: 278 وحدة\لتر (الطبيعي: 36-92)
بيليروبن المصل الكلي: 1.1 مغ\دل (الطبيعي: 0.3-1.2)

كتابة حرة وطرح موضوع النقاش!

1- What is the most likely diagnosis?

2- In addition to a fasting serum lipid profile, which of the following studies would most likely help establish the diagnosis and WHY?

A) Antimitochondrial antibody assay
B) Serum 25-hydroxyvitamin D
C) Endoscopic retrograde cholangiopancreatography
D) Abdominal ultrasonography

1- ما هو التشخيص الأكثر احتمالا ؟

2- إضافة إلى معايرة شحوم المصل أثناء الصيام. اي من الدراسات التالية هو الأكثر قدرة على المساعدة في التشخيص ولماذا:

أ) معايرة أضداد المتقدرات.
ب) معايرة 25hydroxyvitamin D المصل.
ج) ERCP.
د) إيكو بطن.


diarrhea+systolic murmur |

حالة سريرية

الوصف الكامل Background
A 58-year-old man presents with complaints of diarrhea for the last one-year, which is watery in nature and accompanied by abdominal cramps. He denies any history of fever, blood per rectum, and foul smelling stools. He took various herbal medicines for the treatment of the diarrhea but nothing seemed to help. General examination shows an elderly patient who appears ill. Physical examination showed hepatomegaly of 3cm below the right costal margin, mild shifting dullness, and no abdominal tenderness. Examination of the chest reveals a 2/6 systolic murmur on the left lower sternal border. He also gives a history of frequent episodes of dizziness, accompanied flushing, and a feeling of warmth. He is depressed about his illness and feels hopeless that his disease might not get diagnosed and treated.

You send his routine laboratory studies, which were as follows
Hb 13gm/dL
MCV 90
WBC 6,100/cmm
Platelet 210,000/cmm
AST 101mg/dL
ALT 99mg/dL
Alkaline Phosphatase 400mg/dL

what is the diagnosis???


abdominal pain+ulcers |

حالة سريرية

الوصف الكامل Background
A 45-year-old male presents to your office with a 6-month history of periodic abdominal pain. He tried several over-the-counter medications including H2 blockers and proton pump inhibitors with moderate success. Workup, including an upper GI series and endoscopy, reveals multiple duodenal ulcers and a single jejunal ulcer. Stool testing shows occult blood and mild steatorrhea. What is the most probable cause of impaired fat absorption in this patient?

A. Pancreatic enzyme deficiency

B. Pancreatic enzyme inactivation
C. Reduced bile salt absorption
D. Defective intestinal absorption
E. Bacterial proliferation


non bloody diarrhea |

حالة سريرية

الوصف الكامل Background
A 45-year-old white male comes to your office for evaluation of diarrhea of 8-months duration. He says that he has lost almost 15 lbs during the past 8 months. He denies any blood in the stools. 24-hour stool collection reveals fecal fat of 10 gm/day. Stool microscopy reveals no pathogens and no leucocytes. D-xylose test was performed which shows that less than 2 grams of D-xylose is excreted in urine in 5 hours. D-xylose test was re-performed after treatment with antibiotics but excretion is still less than 2 grams in 5 hours. Based on these findings, what is the most likely diagnosis in this patient?

A. Lactose intolerance
B. Bacterial overgrowth
C. Pancreatic insufficiency
D. Whipple’s disease
E. Terminal ileal disease


Celiac sprue case |

حالة سريرية

الوصف الكامل Background
-A 32-year-old man has a 15-year history of celiac sprue. He admits to being noncompliant with
the diet prescribed over the past 6 months and he has lost 15 pounds during that time in
association with frequent diarrhea. Which of the following will be most likely to occur in this
patient?
A. Iron deficiency will produce a microcytic anemia
B. Vitamin A deficiency will produce nystagmus
C. Vitamin B12 deficiency will produce a megaloblastic anemia
D. Vitamin D deficiency will produce hypercalcemia
E. Vitamin K deficiency will produce hypokalemia

Pain in the right lower quadrant |

حالة سريرية

الوصف الكامل Background
A 24-year-old white woman comes to the physician complaining of 6 months of crampy abdominal pain. The pain has been localized to the right lower quadrant and is made worse by eating. She has also noted an increase in the number of her bowel movements to approximately four per day, and the stools have become semi-formed. She denies any fevers, chills, or night sweats during this period. She has lost 15 pounds from her baseline weight of 128 pounds over the past 6 months. She has also noted aching in her knees and ankles during this interval. On physical examination, she is slightly pale and has two oral ulcers that are covered by a gray exudate and surrounded by an erythematous halo on the inner lower lip. The abdomen is soft but tender in the right lower quadrant. No masses are palpable, and there is no hepatosplenomegaly. A rectal examination reveals brown stool, which is guaiac positive.
Which of the following diagnostic tests would be most appropriate for this patient?

A. Abdominal CT scan
B. Barium enema
C. Sigmoidoscopy
D. Abdominal sonogram scan
E. Upper gastrointestinal and small bowel barium x-ray films

ألم بطني حاد في الجانب الأيسر، ما السبب ؟ |

حالة سريرية

الوصف الكامل Background

ألم بطني حاد في الجانب الأيسر,ما السبب ؟
مريض عمره 75 سنة من أصل أمريكي إفريقي نقل من دار العجزة إلى الإسعاف بشكوى ألم بطني حاد في الجانب الأيسر من البطن بدأ في الحفرة الحرقفية اليسرى .
خلال الانتظار لمعاينته بدأ المريض بإمرار براز مختلط بخثرات دموية غامقة .
علاماته الحيوية :الحرارة 38,1 c, BP:100/85,Pulse:120/min,respiration:18\د.
فحص البطن أظهر مضض موضع على مسير الكولون النازل .
تم إجراء صورة بطن بسيطة بعد صورة الباريوم ولم تظهر وجود هواء حر ولكنها أظهرت أن لمعة الامعاء الغليظة متضيقة وغير منتظمة وتسمك المخاطية وتسمك جدار الكولون ,

ما هو التشخيص الأكثر احتمالا ؟
1-التهاب زائدة
2-سرطان كولون
3-داء كرون
4-التهاب كولون إقفاري
5- التهاب كولون قرحي .


نزف هضمي 3 |

حالة سريرية

الوصف الكامل Background
A 38 year old woan had undergone a parietal cell vagotomy for persisting duodenal ulcers. 3 months later she experienced an upper gastrointestinal hemorrhage and a recurrent ulcer was diagnosed. 2 days after the operation she had a severe epigastric and back pain. Her vital signs are:
PR: 110\ m
, BP: 120\80,
RR: 15\ M ,
T:37
Abdominal ultrasound shows some swelling of the pancreas.

Labs:
HB:13,8
WBC:12,800
Na: 142
CL: 110
K:4,2
HCO3: 25
Ca:11,4
PH:1,1
Amylase: 772

Which of the following studies is the most appropriate?
A- acid output studies
B- gastrin and calcitonin levels
C- parathyroid hormon and gastrin levels
D- parathyroid hormon and calcitonin levels
E- calcitonin and urinary VMA levels


نزف هضمي سفلي & نفخة انقباضية |

حالة سريرية

الوصف الكامل Background
An elderly caucassian male brings in his wife, a 65 year old lady to their family physician with complaints of painless intermittent rectal bleeding. She describes the bleeding as bright red in color. She denies any abdominal pain, nausea or vomitting. Her medical history is significant for hypertension, diabetes mellitus, hypercholesterolemia.
Her vitals are:
BP: 140\80
PR: 80\m
RR: 16\m
T: 36.7
On examination an ejection systolic murmur is detected in the right second intercostal space. The remainder of the examination shows no abnormalities. Sigmoidoscopy is unremarkable. Which of these is the most likely diagnosis in this patient?
A- vascular actasia
B- diverticulosis
C- ischemic colitis
D- carcinoma colon
E- hemorrohids

نزف هضمي علوي، ما هي الخطوة الأولى؟ |

حالة سريرية

الوصف الكامل Background
A 37 Year old disease with a history of peptic ulcer disease is brought to the emergency room for an alleged episode of hematemesis. A nasogastric tube lavage reveales cofee ground material. Physical examination reveals pallor, delayed capillary refill without cyanosis.
His vitals:
BP:85\40,
PR: 125
, RR:18\M
, T: 37,7.
WHAT should be the first step in the management of this patient?
A- IV octreotide
B- Surgical intervention
C- Upper GI endoscopy
D- Fluid resussitation
E- IV omeprazole

نزف هضمي 1 |

حالة سريرية

الوصف الكامل Background
A 37 Year old disease with a history of peptic ulcer disease is brought to the emergency room for an alleged episode of heamatomesis. A nasogastric tube lavage reveales cofee ground material. Physical examination reveals pallor, delayed capillary refill without cyanosis.
His vitals:
BP:85\40,
PR: 125
, RR:18\M
, T: 37,7.
WHAT should be the first step in the management of this patient?
A- IV octreotide
B- Surgical intervention
C- Upper GI endoscopy
D- Fluid resussitation
E- IV omeprazole

ألم بطني شديد ومترقي منذ سنة، ما السبب يا ترى؟ |

حالة سريرية

الوصف الكامل Background

مريضة عمرها 83 سنة أحضرت بقصة ألم بطني يشديد مترقي منذ سنة ,الألم يشتد بعد الطعام و المريضة بدأت بتجنب الطعام بسبب الألم, الألم غالبا يترافق مع تطبل بطن وغثيان واقياء وإسهال.
مؤخرا لاحظت المريضة أن برازها أصبح كبير الحجم و رغوي ودهني المريضة فقدت 15 كغ من وزنها خلال السنة الماضية .
الأمراض الأخرى التي تعاني منها المريضة :ارتفاع التوتر اشرياني والسكري النمط2 وفرط كولسترول الدم والداء الوعائي المحيطي واحتشاء العضلة القلبية .
بالفحص البطن لين وغير متمدد .,صورة البطن البسيطة والCT طبيعيان .

ما هو التشخيص الأكثر احتمالاً؟ ولماذا ؟

1-التهاب بنكرياس مزمن
2-تصلب عصيدي للشرايين المساريقية
3-داء كرون
4-متلازمة الأمعاء الهيوجة
5-الداء الزلاقي
6-حصيات مرارية عرضية
7-الداء النشواني
8-لمفوما معوية


ألم بطني بالربع العلوي الأيمن بدون يرقان |

حالة سريرية

الوصف الكامل Background

رجل 65 عاماً شخص له سابقاً الداء السكري وارتفاع الضغط، راجعك في الإسعاف بشكوى ألم بطني حالي متوضع في الربع العلوي الأيمن مترافق مع غثيان. الألم لا يحدث للمرة الأولى. الفحص السريري بيّن كتلة مجسوسة في الربع العلوي الأيمن. درجة حرارته كانت 38.8.

الفحوص المخبرية: total bilirubin level of 1.99 mg/dl (direct 0.59 mg/dl); SGOT 1.26 mg/dl; Na 135 mmol/l and K 2.9 mmol/l. The white blood count was 15200/μl with 92.2% neutrophiles.

كتابة حرة وطرح موضوع النقاش!

أ. ما الخطوة التالية الأكثر مناسبة في تقييم حالة المريض؟ ولماذا؟ (عدد الأجوبة الكافية لوضع الجواب الصحيح والشرح، جواب واحد فقط)

1. تسكين الألم مباشرة كي لا يدخل المريض صدمة ألمية؟
2. سوائل وريدية بشكل هجومي Aggressive؟
3. صورة بطن x-ray؟
4. إيكو بطن؟
5. ERCP؟

سأطرح خمس أسئلة متوالية عن هذه الحالة مع صورة مرفقة، أرجو الالتزام بعدم مناقشة سوى الفكرة المطروحة. ووضع الجواب مع الشرح Very Happy


شبو مريضنا الثاني ؟ |

حالة سريرية

الوصف الكامل Background
A 57-year-old woman has had a 2-cm gastric ulcer at the midpoint of the lesser curvature of the stomach for 3 months. The ulcer was first diagnosed endoscopically because of a history of epigastric pain and one episode of vomiting with a trace of blood. At the first endoscopy multiple biopsies were read as negative for cancer, and also negative for the presence of H. pylori. She was treated with dietary measures and H2 blockers. On re-endoscopy 6 weeks later, the ulcer was essentially unchanged. Biopsies were again negative for malignancy and for H. pylori. Serologic tests and breath tests for H. pylori were also negative. Her H2 blockers were replaced by omeprazole, and sucralfate and misoprostol were added to her therapeutic regimen. At the current endoscopy, 6 weeks after the second one, the ulcer was slightly smaller but still present. Biopsies were not taken because she was gagging and the procedure had to be terminated. Which of the following is the most appropriate treatment at this time?
a- Addition of anticholinergics to her current regimen
b- Antrectomy that includes excision of the ulcer
c- Empiric antibiotics to eradicate H. pylori
d- More of the same for another 6 weeks
e- Vagotomy and pyloroplasty

cirrhosis case |

حالة سريرية

الوصف الكامل Background
A 46-year-old man with alcoholic cirrhosis comes to the emergency department because of hematemesis. He had been doing well until this bleeding episode occurred. Upper endoscopy demonstrates large esophageal varices, which are ligated. The patient is hospitalized, and octreotide is administered.

On physical examination on admission, the patient is alert and oriented. Pulse rate is 84/min, and blood pressure is 110/60 mm Hg. Mild muscle wasting and spider angiomata are present. There is no asterixis or ascites.

Laboratory Studies
Hemoglobin

12.8 g/dL (128 g/L)
Leukocyte count

6400/μL (6.4 × 109/L)
Platelet count

83,000/μL (83 × 109/L)
Serum aspartate aminotransferase

73 U/L
Serum alanine aminotransferase

31 U/L
Serum total bilirubin

2.2 mg/dL (37.62 μmol/L)
Serum albumin

3.1 g/dL (31 g/L)
INR

1.3

Abdominal ultrasonography shows a coarse echotexture of the liver and no ascites.

كتابة حرة وطرح موضوع النقاش!
Which of the following is most appropriate at this time?

A Transjugular intrahepatic portosystemic shunt
B Norfloxacin
C Transfusion of two units of packed red blood cells
D Transfusion of fresh frozen plasma
E Vasopressin

please explain your answer.


Surveillance colonoscopy |

حالة سريرية

الوصف الكامل Background
A 45-year-old woman is undergoing evaluation to determine the cause of iron deficiency anemia. The patient is otherwise healthy, and family history is unremarkable. Colonoscopy shows a 2-cm villous adenoma in the sigmoid colon; the adenoma is removed during the procedure.
كتابة حرة وطرح موضوع النقاش!
In addition to counseling regarding screening of family members, which of the following is most appropriate at this time?

A Repeat colonoscopy in 6 months
B Repeat colonoscopy in 3 years
C Repeat colonoscopy in 10 years
D Annual fecal occult blood testing
E Referral for left hemicolectomy

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