حالة سريرية
لايوجد
HISTORY — A 20-year-old man with end-stage renal disease and a painful, violaceous, plaque-like skin eruption over the lower extremities was admitted to the hospital. His past medical history was remarkable for a rapidly progressive glomerulonephritis, an unsuccessful cadaveric renal transplant, and poorly controlled hypertension. Shortly after admission, he developed respiratory distress requiring mechanical ventilation. Over the next few weeks, his skin lesions spread to the abdomen and back and became ulcerative and necrotic, forming eschars. The patient eventually required tracheotomy for chronic ventilator support.
HOSPITAL COURSE — Later in the hospitalization, the serum calcium increased to 14 mg/dL, and a serum mid-chain parathyroid hormone level was increased at 246 pg/mL. A skin biopsy revealed diffuse subcutaneous and vascular calcification with in situ thrombosis. A bone scan is shown
PHYSICAL EXAMINATION — Afebrile; respirations 24 on the ventilator; blood pressure 100/90. General: chronically ill appearing. Chest: scattered rhonchi. Cardiac examination: II/VI systolic ejection murmur at the left sternal border. Skin: multiple plaque-like lesions with areas of necrosis, ulceration, and eschars.
???
LABORATORY FINDINGS — Hct 19.7 percent; WBC 14,500/mm3. Na+ 125 mEq/L; K+ 3.6 mEq/L; Cl - 89 mEq/L; HCO3 -16 mEq/L; BUN 95 mg/dL; creatinine 10.3 mg/dL; phosphate 6.5 mg/dL; calcium 7.2 mg/dL. Chest radiograph : diffuse infiltrates. Right heart catheterization: PAOP 12 mmHg; CI 3.7 L/min/m2; SVR 1170 dyne sec cm -5.
???
QUESTION — What is the cause of the patient's respiratory failure?
راجع شاب 28 سنة قسم الاسعاف بعد ابتلاع شكالتين معدنيتين منذ 6 ساعات . أظهرت الصورة الشعاعية أن الشكالتين متوضعتين بالأمعاء الدقيقة , ما التدبير الأمثل للمريض ؟
1- اعطاء صادات وريدية
2- اعطاء 250 ملغ سيترات مغنزيوم لتحريض الاسهال
3- المتابعة بالصور الشعاعية و فحص البطن
4- تداخل جراحي فورا
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 .
What anatomical structures are involved in the afferent pathway of the physiologic response to maintain this patient's blood pressure?
A. Aortic arch transmits via vagus nerve to medulla
B. Aortic body transmits via vagus nerve to medulla
C. Carotid body transmits via glossopharyngeal nerve to medulla
D. Carotid sinus transmits via glossopharyngeal nerve to medulla
E. Carotid sinus transmits via vagus nerve to medulla
أتت السيدة (م.س) البالغة من العمر 60 عاما بحالة بسبات مع فرط تهوية دون تعرضها لقصة رض ولدى سؤال مرافقيها تبين أنها مصابة بالقصور الكلوي المزمن والداء السكري منذ عدة سنوات وكذلك تبين أنها استأصلت كتلة (ميلانوما) خلف الاذن مع انتقالات ورمية للدماغ.....
ولقد تم إجراء العديد من الفحوصات السريرية والكيميائية ولكنني لم ادرجها الآن منتظرا منكم أن تتطلبوها لأجيبكم بالفحص وبنتيجته
من الواضح في قصة السريرية أن المريضة مؤهبة لحدوث السبات لعدة اسباب........
بانتظار مشاركتكم
A. Vitamin D deficiency
B. Vitamin C deficiency
C. Iron deficiency
D. Folate deficiency
E. Chronic hemolysis
F. Anemia of chronic disease
G. Vitamin B12 deficiency
H. Copper deficiency
A. Mr. Mathews, How much would you like to know about your condition?
B. Mr. Mathews, I am sorry to tell you that you have lung cancer and it is fairly advanced.
C. Mr. Mathews, What do you think about your symptoms?
D. Mr. Mathews, Unfortunately, the situation is more serious than what I earlier thought.
E. Mr. Mathews, Would you like to have some one else with you as I don't have good news for you?
A 34-year-old Hispanic male comes in after being involved in a
street fight. He complains of painful and swollen left arm. X ray
shows fracture of midshaft of humerus. The neurovascular
examination is normal in left arm. Closed reduction of facture is
done and arm is kept in hanging cast. One hour later the patient
complains of numbness in the left wrist with marked limitation of
extension at wrist. Which of the following is the most likely
diagnosis at this time?
A.Radial nerve injury.
B.Brachial artery injury.
C.Compartment syndrome.
D.Ulnar nerve injury.
E.Median nerve injury
A 32-year-old man has had increasing lower abdominal pain, mild
diarrhea and rectal pain on defecation, since 3 days. 10 days ago
he had right lower quadrant (RLQ) pain, for about 24 hours that
resolved spontaneously. Since then, he has had malaise and low-
grade fever. His vital signs are, PR: 110/min; BP: 150/90mm of
HG; RR: 15/min; Temperature: 38.7C(101.6F). He has low
abdominal tenderness, without rebound. No masses are palpable.
Bowel sounds are present. Rectum is very tender and boggy and a
fluctuant bulging is palpated with the tip of the finger anteriorly.
Laboratory results are:
Hb
13.5
WBC
16,700cmm
ESR
38
Most probably this is a complication of:
A.Anorectal abscess
B.Invasive diarrhea
C.Acute appendicitis
D.Diverticulitis
E.Colon cancer
A 45-year-old woman underwent elective surgery for an inguinal
hernia. In the postoperative recovery room, she developed
nausea, vomiting, and acute abdominal pain. Her other medical
problems include systemic lupus erythematosus, pernicious
anemia, type-1 diabetes, chronic low back pain, and uterine
fibroids. Her preoperative medications include monthly vitamin B-
12 injections, insulin, prednisone, hydroxychloroquine, and
acetaminophen. Her blood pressure is 70/40 mmHg and heart rate
is 110/min. Initial labs showed blood glucose of 50 mg/dL. What is
the most probable cause of this patient’s condition?
A.Postoperative bleeding
B.Diabetic ketoacidosis
C.Intra-abdominal abscess
D.Intestinal obstruction
E.Adrenal insufficiency
F.Allergic reaction
G.Insulin-induced hypoglycemia
H.Atelectasis
I. Bleeding into uterine fibroid
A 35-year-old Mexican male undergoes an exploratory laparotomy,
for intractable abdominal bleeding. A ruptured spleen is found and
a splenectomy is performed. During anesthesia he is administered
oxygen, nitrous oxide, muscle relaxant and narcotics. Surgery is
uneventful and no blood products are administered. His vitals
immediately after extubation are, RR: 9/min; BP: 160/90mm Hg;
PR: 130/min. His neurological examination is normal. However, his
vitals after 1 hour are RR: 7/min; BP: 110/60mm Hg; PR: 70/min.
His arterial blood gases show pH: 7.30; pCO2: 50 mmHg and pO2:
70 mmHg. What is the most likely cause of these findings?
A.Postoperative hypotension due to bleeding.
B.Cardiogenic shock.
C.Delayed emergence from anesthesia.
D.Another source of bleeding, which was overlooked.
E.Acute respiratory distress syndrome
A.Agree to show her the records only after she undergoes treatment for her depression
B.Attempt to arrange to review her clinic records with her as soon as possible
C.Discuss her case with a lawyer prior to showing her the records
D.Explain to her that physician-patient confidentiality prohibits her from seeing her medical record
E.Immediately make copies of her medical record for her to review at her convenience
A 2-year-old boy was diagnosed with hydrocephalus shortly after birth. At age 3 months he
had a ventriculoperitoneal shunt placed. The family has been instructed to manually pump the
shunt at regular intervals, and they know where the pump is located over the rib cage. In the
last 3 days the child has become irritable, complains of headache, and has developed nausea
and vomiting. This morning the family noted impairment of upward gaze. These symptoms
suggest which of the following situations?
A. Intracranial bleeding
B. Obstruction of the shunt
C. Shunt infection
D. The child has outgrown the shunt
E. The child no longer needs the shunt
قصة المرض الحالية : مريض 51 سنة , عامل بناء , يشكو من الم اسفل الظهر بدأ بعد حمله لصندوق ثقيل من اسبوع مضى , المه حاد وينتشر للفخذ الايسر وبعض الاحيان للقدم اليسرى وحدد المريض درجة المه –على مقياس من عشرة بحيث 1 هو الاخف و10 الاشد – ب 8 من 10 .
يسوء الالم بالحركة والسعال والجلوس لفترات طويلة , ولكنه يتحسن بالاستلقاء وجزئيا ب الايبوبروفين (مضاد التهاب غير ستيروئيدي) .
ينكر المريض عدم استمساك غائطي او بولي او ضعف او فقد حس بالطرف السفلي , لا حرارة او تعرق ليلي او نقص وزن . لا يشكو من صعوبة تبول او افراغ غير كامل للمثانة
لمدة ستة اشهر, ولديه الم اسفل ظهر و الم قدم متقطع من سنة .
فصح باقي الاجهزة : سلبي ما عدا ما ذكر فوق
تحسس : البنسلين ويسبب طفح
سوابق مرضية : لا يوجد
سوابق جراحية : لا يوجد
قصة اجتماعية : مدخن باكيت يوميا لمدة 18 سنة ,يشرب كأسي بير باعطل نهاية الاسبوع
سوابق عائلية : لا يعلم
الفحص السريري : المريض متضايق قليلا بسبب الالم الظهري
الظهر : مضض بالعضلات جانب الظهرية بالجانبين , مجال حركة طبيعي , لا حرارة او احمرار
الاطراف :2+ المأبضي ظهر القدم و الظنبوبي الخلفي مجسوسة بالطرفين , الورك طبيعي لاتحدد بالحركة بالجانبين .
عصبيا : حركيا : القوة 5 من 5 بكل الاطراف
المنعكسات : متناظرة ++
لا يوجد بابنسكي
المشية : طبيعية ( متضمنة المشي على الكعب و لاصابع ) ,لازك سلبية .
الحس : سليم
B. do not intubate patient but administer morphine and dopamine together to alleviate his suffering while maintaining his blood pressure
C. do not intubate the patient but administer morphine for comfort even though this might lower his blood pressure and respiratory rate and hasten the patient's demise
D. contact the hospital ethics committee to decide on the proper course of action
E. intubate the patient for now; when the situation is more stable discuss the patient's end of life wishes with the family
An HIV-positive 37-year-old homeless man with schizophrenia, paranoid type, is admitted to the hospital because of a dry cough, hemoptysis, weakness, fever, sweating, and weight loss. He came voluntarily, wanting to get "something for the cough" but after the necessary tests were performed he was admitted because of the possibility of active tuberculosis. On the unit he is started on anti-tuberculosis medication and antipsychotics. Initially he is cooperative with therapy. After two days in the hospital, however, he begins yelling at the nurses and demands to be discharged. He is determined to get out of the hospital and any conversation to persuade him that he needs treatment is futile. He threatens to sign himself out of the hospital against medical advice. Which of the following facts should lead the physician in charge of his care to justify involuntary commitment?
A.
The patient has schizophrenia
B.
The patient has tuberculosis
C.
The patient is agitated
D.
The patient is HIV positive
E.
The patient is homeless and unable to keep follow-up appointments
A 68-year-old woman comes to the physician's office because of recent depression. She feels tired, lazy, has no energy, and describes herself as being in "slow motion." She has difficulty concentrating and is very forgetful. She feels down and describes herself as apathetic. She sleeps and eats more than usual and has gained some weight. She has no prior history of mental illness and her family history is negative. She denies any recent stressors and so does her family. The treating physician remembers that a first episode of depression in later life is not uncommon. In diagnosing and treating major depressive disorder in a patient with no prior psychiatric history, however, one should always rule out organic etiologies of depression. Which of the following disorders presents with a clinical picture of retarded depression?
A.
Hyperthyroidism
B.
Islet cell tumors
C.
Multiple myeloma
D.
Pheochromocytoma
E.
Vitamin D deficiency
مريض سكري من النمط الأول عمره 49 سنة جاء بقصة زلة جهدية منذ شهرين . تسوء الز لة بعد مسير 2-3 blocks.نفى المرض وجود ألم صدري أو في الفك أو الحلق أو اليد عند الجهد أو الراحة.
يتناول المريض إضافة للأسولين الأسبرين وAtorvaststin (خافض لشحوم الدم ) .
بالفحص السريري كان الضغط 160/90 بينما كانت بقية الفحوص وإيكو القلب ضمن الحدود الطبيعية .
ما هو التشخيص الأكثر احتمالاً :
A -آفة رئوية سادة مزمنة
B - اعتلال قلب توسعي
C- آفة في الأوعية الإكيلية
D - ضيق أبهري
E - تليف رئوي
: الجواب هو رقم C
الهدف من هذه الحالة : دراسة ما يسمى ( Anginal equivalent ) أو مشابهات الخناق عند مريض سكري
يجب الاشتباه بوجود مشابهات الخناق عند هذا المريض السكري ( Anginal equivalent ) حيث أن المرضى السكريين قد لا يشعرون بالألم الخناقي ( الألم الصامت ) لذا يجب هنا إجرء اختبار الجهد للتأكد .
بما أن الفحوص الأخرى الرئة والقلب طبيعية فهذا يبعدنا عن التفكير بالآفات الرئوية السادة المزمنة والتليف الرئوي وتضيق الأبهر . أما اعتلال القلب التوسعي فهو ممكن ولكنه اقل احتمالاً من آفات الأوعية الاكليلية وإمكانية علاجه أقل .
تعد المعالجة بالنترات والنتروغليسرين أمراً ضرورياً عند هذا المريض .وهنا نشير إلى أنه عندما تكون عند مريض قصة سكري وارتفاع بالتوتر الشرياني يجب إعطاؤه مثبطات خميرة تحول الأنجيوتنسين للسيطرة على ارتفاع الضغط وللوقاية من حدوث آفة متقدمة في الأوعية الاكليلية . وحتى عند المرضى الذين ليس لديهم ارتفاع في التوتر الشرياني فإن إعطاء كميات منخفضة من مثبطات خميرة الأنجيوتنسين يساهم في خفض نسبة الوفيات وخفض نسب حدوث الاحتشاء وقصور القلب عند المرضى المؤهبين لذلك كما آن نسب الاختلاطات العينية والكلوية بسبب السكري تنقص أيضاً عند تناول هذا الدواء .
45 years old married lady came to ER complaining of abdominal pain for the last 3 days and today she noticed blood in her stools, no diarrhea, no constipation, no previous history of hemorrhoids or anal pain.
the patiant is hyperlipidemic and suffers multi-arthralgias and she is using the following perscribed medications:
tramadol
diclofenac sodium
pravastatin
orlistat
calcium carbonate + vit d3
adavit
lansoprazole
what do you think is happening with the patiant?
what is your next step?
You decide to
A/ Not write the letter and tell her why you cannot
B/ Write a letter to the airline asking them to change their refund policy
C/ Write the letter she asks , but only this once
D/ Not write the letter and report her to the airline for attempted fraud
E/ Tell her to write the letter and use your name
44yo f presetns with a weight gain of >11 kg
over the past 2 months.
she quit smoking 3 months ago and is on amitriptyline for deppression
she also reports cold intorelance and constipation
what are the differential diagnosis?I need 5
and what is the workup"tests"
weight gain
During his Montreal performance, the entertainer appeared to be in pain not only from his abdomen, but also from a recent ankle injury. He finished the performance, and then boarded a train for Detroit, where a sold-out audience awaited his next performance. Because the pain became much more severe, the patient wired ahead, asking for a physician to meet him on his arrival in Detroit.
About 48 hours later he arrived, feeling much worse. He was quoted as saying: "I'll do this show even if it's my last." Rather than disappoint the large audience gathered to witness his performance in Detroit, the performer, although acutely ill, immediately went on stage.
After performing, the patient returned to his dressing room where he complained of abdominal pain, which gradually increased and was accompanied by weakness. After struggling through his performance, he was examined by a physician.
Postoperatively he continued to be febrile, with a temperature of 101° F and rapid pulse, but was alert and responsive. Because of persistent postoperative ileus, he was reoperated approximately 4 days after the initial laparotomy. He failed to recover and died 10 days after the initial onset of symptoms.
1. What is your diagnosis?
A) Perforated peptic ulcer
B) Splenic rupture
C) Appendicitis
D) Acute pancreatitis
2. Who was our mystery patient?
A) Rudolf Valentino
B) Charlie Chaplin
C) Ehrich Weiss
D) Jerry Garcia
[/eng]
Not all patients with HIV present with recognizably HIV-related symptoms or signs. 1
A careful 'high-risk' history is important but not always helpful. 2
If there is a possibility of HIV infection, an HIV antibody test should always be done after appropriate counselling. 3