حالات سريرية

challenging and unsolved case- |

حالة سريرية

الوصف الكامل Background
I saw this case 1 week ago and I am still wroking on it. (not solved yet) I thought it could be a good study case for interested people. Feel free to ask any question, add any comments and try to answer my questions
الشكوى الرئيسية CC
Diarreah and abominal pain for
القصة المرضية HPI
Forty three Y old patient presents with sever vomiting , abdominal pain and diarrhea that has been getting worse for the last few weeks. There is an episodic nature to patients symptoms (episodes of cramps diarrhea and vomiting lasting for 1-3 days), but the episodes are getting more frequent (from one every month or two to once every week and becoming more sever. He describes diarrhea 7-9 times per day : medium to large amount associated with cramps, watery non bloody and awakens him from his sleep. There has not been any clear relationship between food and the diarrhea that seems to be there even if he does not eat. Diarrhea started about 4 years but has increased over the last week weeks to months leading to 10 kg weight loss. As for vomiting it is for old undigested food and it is not as persistent or bothering as the diarrhea. No hematemesis and no dysphagia are present. As for the abdominal pain it is mid abdominal ,described as cramps and decreases after he passes the stool (diarrhea). No aggravating factors ,yet he is afraid of eating . Patient denies heartburn, fever , chills , night sweats ,joint pains or skin rashes.
الأجهزة الأخرى ROS
Review of systems: negative other wise . No cardiac , neurologic, pulomary, hepatic, urinary, skin, or joint symptoms . Just generalized fatigue
السوابق المرضية الشخصية PMH
PMH (past medical history): was diagnosed with HTN years ago but for months has not been taking medications. He was diagnosed with bleeding aneurysm in the brain that was coiled successfully 10 years ago
السوابق المرضية العائلية FMH
PSH : No abdominal surgery

Medications : None for the time being

Family history : He has nine siblings. Two died in car accidents. One sister had a prolonged course of diarrhea and the died after she had surgery and they ?? discovered some type of tumor at age of 47. No other cancer in the family to his knowledge. Father is alive and healthy . Mother died of ? Heart related problems

الوضع الصحي والاجتماعي SH
Social history : No smoking , alcohol or drugs . He is employed in office job. No exposure to chemicals

Allergies : None

الفحص السريري Clinical Exam
On examination
BP 85/55 , Temp 37.1 RR 16 Hr 80
General appearance : thin middle aged man ,dehydrated in pain with no respiratory distress
HEENT : No pallor No icterus. Pupils equal round reactive, Extra ocular movements intact. Oral mucosa dry no rashes , throat is clear
Lungs : Clear to auscultation
CVS: S1 S2 normal no murmurs or additional sounds or rubs
Abdomen : Soft , mild periumbilical tenderness no rebound and normal sounds. No hepatoseplenomegaly
Extremities : normal pulses , no edema no clubbing
CNS : Alert ,oriented X 3 with no focal deficits
الاستقصاءات Investigations
Initial labs : Na 141 , K 2.3 (very low), Creatinine 0.8, (AST , ALT) normal , Calcium 6.8 ,Albumin 3.1, Magnesium 1.6, CRP 0.2 , Bicarbonate 15.9, Cholride 125, LDH 108, B 12 level 137 (low) , serum folate 20 (slightly high) ,
Random cortisol level 18.5 (done at 10: 45 PM),
WBC 9.4 with 77% neutrophils (slightly up) and otherwise normal differential. Lymphocytic count is 1.2 (low normal) (12.9%). Hemoglobin 15.1 with MCV of 107.8
PT 15.5 (prolonged)
ESR 15 (normal)

Stool analysis : Mucoid with not WBC's or RBC's and negative for ova and parasites
TSH 3.5
CT scan abdomen reports large paraesophageal hernia. Significantly dilated duodenum , the oral dye goes to the colon (no complete obstruction) . There is osteopenia and compression fracture of L12 vertebral body. The CBD moderately dilated and a question is raised about distal CBD narrowing / compression but no frank mass seen.

التدبير Managment
Patient gets > 150 meq of K IV, + Linger lactate for rehydration . Surgical evaluation (based on examination recommends no surgical intervention and for medical care

Questions :
What do you think about the patient diarrhea?
What is the work up you like to obtain?
What do you think about the Dilated CBD?

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...

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

إسهال خمجي Infectious Diarrhea 3 |

حالة سريرية

الوصف الكامل Background
A 34-year-old Caucasian male presents to your office with complaints of diarrhea.

The patient has just returned from a trip to South America, where he developed foul-smelling stools, abdominal cramps and bloating.

He has had the above symptoms for the past 4 weeks band obtained no relief from a three-day course of ciprofloxacin.

His vital signs are stable.
The physical examination is unremarkable.

رجل قوقازي عمره 34 سنة يشكو من إسهال.

كان المريض قد قدم من رجلة إلى أمريكا الجنوبية, حيث عانى هناك من إسهال كريه الرائحة, مغص بطني وتطبل.

دامت هذه الأعراض عنده خلال الـ 4 أسابيع السابقة دون أن تزول باستعمال السيبروفلوكساسين.

علاماته الحيوية طبيعية.
الفحص السريري طبيعي.

كتابة حرة وطرح موضوع النقاش!
What is the most appropriate next step for this patient?

A.Schedule colonoscopy.
B.Obtain CT scan abdomen.
C.Prescribe oral metronidazole.
D.Prescribe another course of ciprofloxacin.
E.Prescribe oral ampicillin.

ما هي الخطوة التالية الأكثر ملائمة لهذا المريض؟

1. إجراء تنظير كولون.
2. إجراء CT للبطن.
3. وصف ميترونيدازل فموي.
4. وصف شوط ثاني من السيبروفلوكساسين.
5. وصف أمبيسيلين فموي.

ابق على تواصل مع حكيم!