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182 Cards in this Set
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A 62-year old man describes epigastric and substernal pain that he cannot characterize well. At times his description sounds like GERD, at times it does not. Sonogram of the gallbladder, ECG, and cardiac enzymes have been negative.
What is this? |
The question is, is it GERD? |
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A 62-year old man describes epigastric and substernal pain that he cannot characterize well. At times his description sounds like GERD, at times it does not. Sonogram of the gallbladder, ECG, and cardiac enzymes have been negative.
How should this patient be managed? |
Esophageal pH monitoring |
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A 54-year old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight clothes, or lying flat in bed at night. He gets symptomatic relief from antacids but has never been formally treated. The problem has been present for many years, and seems to be progressing.
What is this? |
The description is classic for GERD |
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A 54-year old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight clothes, or lying flat in bed at night. He gets symptomatic relief from antacids but has never been formally treated. The problem has been present for many years, and seems to be progressing.
How should this patient be managed? |
Since the diagnosis of GERD is not really in doubt, he may be treated with symptomatic medication - however on questions you should recommend endoscopy and biopsies to assess the extent of esophagitis and potential complications!! |
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A 54-year old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight clothes, or lying flat in bed at night. He gets symptomatic relief from antacids but has never been formally treated. The problem has been present for many years, and seems to be progressing. Endoscopy shows severe peptic esophagitis and Barrett esophagus.
How should this patient be managed? |
Management for Barrett has evolved, and Barrett is no longer considered an indication for surgery. In this patient who has not had formal medication management, that should be the first step. Continued symptoms would warrant consideration for fundoplication. Dysplastic changes would require resection. |
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A 54-year old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight clothes, or lying flat in bed at night. He gets brief symptomatic relief from antacids, but in spite of faithful adherence to a strict program of medical therapy, the process seems to be progressing. Endoscopy shows severe peptic esophagitis with no dysplastic changes.
How should this patient be managed? |
He has failed medical management and has no dysplastic changes. He needs a fundoplication. |
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A 47-year old woman describes difficulty swallowing, which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to "make it through." Occasionally she regurgitates large amounts of undigested food.
What is this? |
Sounds like achalasia |
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A 47-year old woman describes difficulty swallowing, which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to "make it through." Occasionally she regurgitates large amounts of undigested food.
How should this patient be managed? |
Diagnosis is suggested by barium swallow (usually the first test) and confirmed by manometry studies. Dilations or surgery are the therapeutic options. |
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A 54-year old black man with a history of smoking and drinking describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to other solid foods, then soft foods, and is now evident for liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds of weight.
What is this? |
Carcinoma of the esophagus (progressive dysphagia, weight loss)
Given the detail of race, age, sex, and habits, it is probably squamous cell cancer. Had the history been longstanding reflux, it would suggest adenocarcinoma. |
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A 54-year old black man with a history of smoking and drinking describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to other solid foods, then soft foods, and is now evident for liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds of weight.
How should this patient be managed? |
The diagnosis is made the same way for both types of esophageal carcinoma: endoscopy with biopsy
The endoscopist wants a "road map" first: barium swallow
**So, (1) BARIUM SWALLOW, (2) ENDOSCOPY and BIOPSY, (3) CT scan (to assess extent) |
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A 24-year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.
What is this? |
Mallory-Weiss tear |
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A 24-year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.
How should this patient be managed? |
- Endoscopy to ascertain the diagnosis. Bleeding will typically be arterial and brisk, but self-limiting. - Photocoagulation can be used if needed. |
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A 24-year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting, and he feels a very severe, wrenching epigastric pain and low sternal pain of sudden onset. On arrival at the ER 1 hour later he still has the pain, is diaphoretic, has fever and leukocytosis, and looks quite ill.
What is this? |
Boerhaave Syndrome (perforation) |
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A 24-year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting, and he feels a very severe, wrenching epigastric pain and low sternal pain of sudden onset. On arrival at the ER 1 hour later he still has the pain, is diaphoretic, has fever and leukocytosis, and looks quite ill.
How should this patient be managed? |
This is a potentially lethal problem. GASTROGRAFIN SWALLOW will confirm the diagnosis and EMERGENT SURGICAL REPAIR will follow. Prognosis depends on the time between perforation and treatment! |
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A 66-year old man has an upper GI endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant retrosternal pain that began shortly after he got home. He looks prostrate and very ill, is diaphoretic, has a fever of 104 F, and a respiratory rate of 30. There is a hint of subcutaneous emphysema at the base of the neck.
What is this? |
Instrumental perforation of the esophagus - the setting plus the air in the tissues are virtually diagnostic. |
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A 66-year old man has an upper GI endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant retrosternal pain that began shortly after he got home. He looks prostrate and very ill, is diaphoretic, has a fever of 104 F, and a respiratory rate of 30. There is a hint of subcutaneous emphysema at the base of the neck.
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Do gastrografin swallow and emergency surgical repair of instrumental perforation of esophagus |
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A 72-year old man has lost 40 pounds of weight over a 2- or 3-month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.
What is this? |
Cancer of the stomach is a possibility |
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A 72-year old man has lost 40 pounds of weight over a 2- or 3-month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.
How should this patient be managed? |
- Diagnosis: endoscopy w/ biopsy, then CT scan - Treatment: surgery will be done for cure if possible, for palliation if not |
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A 54-year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a BM or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. Five years ago he had an ex lap for a gunshot wound of the abdomen.
What is this? |
Mechanical intestinal obstruction, caused by adhesions |
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A 54-year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a BM or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. Five years ago he had an ex lap for a gunshot wound of the abdomen.
How should this patient be managed? |
- NG suction - IV fluids - Careful observation |
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A 54-year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a BM or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. Five years ago he had an ex lap for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on NG suction and IV fluids, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness.
What is this?
What is this? |
He has strangulated obstruction, ie, a loop of bowel is dying - or dead - from compression of the mesenteric blood supply |
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A 54-year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a BM or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. Five years ago he had an ex lap for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on NG suction and IV fluids, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness.
How should this patient be managed? |
Emergency surgery |
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A 54-year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a BM or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and he explains that he used to be able to "push it back" at will, but for the past 5 days has been unable to do so.
What is this? |
Mechanical intestinal obstruction caused by an incarcerated (potentially strangulated) hernia |
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A 54-year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a BM or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and he explains that he used to be able to "push it back" at will, but for the past 5 days has been unable to do so.
How should this patient be managed? |
After suitable fluid replacement he needs urgent surgical intervention |
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A 55-year old woman is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent JVP is noted on her neck.
What is this? |
Carcinoid syndrome |
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A 55-year old woman is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent JVP is noted on her neck.
How should this patient be managed? |
- 24-hour urinary collection for 5-hydroxy-indolacetic acid - Perform a CT scan to assess for liver metastasis - Plan resection based upon results |
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A 22-year old man develops anorexia followed by vague periumbilical pain that several hours later becomes sharp, severe, constant, and well localized to the right lower quadrant of the abdomen. He has abdominal tenderness, guarding, and rebound to the right and below the umbilicus, temperature of 99.6 F and WBC count of 12,500, with neutrophilia and immature forms.
What is this? |
Acute appendicitis |
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A 22-year old man develops anorexia followed by vague periumbilical pain that several hours later becomes sharp, severe, constant, and well localized to the right lower quadrant of the abdomen. He has abdominal tenderness, guarding, and rebound to the right and below the umbilicus, temperature of 99.6 F and WBC count of 12,500, with neutrophilia and immature forms.
How should this patient be managed? |
Perform emergency appendectomy. If the case has not been typical, do CT scan. |
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A 59-year old man is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only for 4+ occult blood in the stool. Lab shows a Hgb of 5 g/dl.
What is this? |
Cancer of the right colon |
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A 59-year old man is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only for 4+ occult blood in the stool. Lab shows a Hgb of 5 g/dl.
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- Diagnosis: Colonoscopy and biopsies - Treatment Blood transfusions and eventual R hemicolectomy |
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A 56-year old man has bloody bowel movements. The blood coats the outside of the stool, and has been present on and off for several weeks. For the past 2 months he has been constipated, and his stools have become of narrow caliber.
What is this? |
Cancer of the distal, left side of the colon |
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A 56-year old man has bloody bowel movements. The blood coats the outside of the stool, and has been present on and off for several weeks. For the past 2 months he has been constipated, and his stools have become of narrow caliber.
How should this patient be managed? |
If given choices, start with flexible proctosigmoidoscopy (45-cm or 60-cm instrument any MD can handle); eventually full colonoscopy (to rule out second primary) before surgery |
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A 77-year old man has a colonoscopy because of rectal bleeding. A villous adenoma is found in the rectum, and several adenomatous polyps are identified in the sigmoid and descending colon.
How should this patient be managed? |
- Premalignant polyps need to be excised and include, in descending order of potential for malignant conversion, familial polyposis (and all variants, such as Gardner), familial multiple inflammatory polyps, villous adenoma, and adenomatous polyp)
- Benign, which can be left alone, include juvenile, Peutz-Jeghers, isolated, inflammatory, and hyperplastic polyps |
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A 42-year old man has suffered from chronic ulcerative colitis for 20 years. He weighs 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Because of a recent relapse, he has been placed on high-dose steroids and Imuran. For the past 12 hours he has had severe abdominal pain, temperature of 104 F, and leukocytosis. He looks ill and "toxic." His abdomen is tender, particularly in the epigastric area, and he has muscle guarding and rebound. X-rays show a massively distended transverse colon, and there is gas within the wall of the colon.
What is this? |
Toxic Megacolon |
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A 42-year old man has suffered from chronic ulcerative colitis for 20 years. He weighs 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Because of a recent relapse, he has been placed on high-dose steroids and Imuran. For the past 12 hours he has had severe abdominal pain, temperature of 104 F, and leukocytosis. He looks ill and "toxic." His abdomen is tender, particularly in the epigastric area, and he has muscle guarding and rebound. X-rays show a massively distended transverse colon, and there is gas within the wall of the colon.
How should this patient be managed? |
Emergency surgery for toxic megacolon, but he also has indications due to chronic ulcerative colitis. The involved colon has to be removed, and that always includes rectal mucosa. |
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A 27-year old man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and Tobramycin for 7 days. Eight hours ago he developed watery diarrhea, crampy abdominal pain, fever, and leukocytosis.
What is this? |
Pseudomembranous colitis from overgrowth of C. difficile |
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A 27-year old man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and Tobramycin for 7 days. Eight hours ago he developed watery diarrhea, crampy abdominal pain, fever, and leukocytosis.
How should this patient be managed? |
- Diagnosis: identify toxin in stool (cultures take too long and proctosigmoidoscopic exam does not always find typical changes)
- Treatment: Clindamycin has to be stopped and anti-diarrheal meds should not be used; Flagyl is the drug of choice (alternate is Vancomycin); failure of medical management with a WBC>50,000 and serum lactate >5 is an indication for emergency colectomy!! |
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A 60-year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.
What is this? |
Internal hemorrhoids bleed but do not hurt whereas external hemorrhoids hurt but do not bleed, thus this is a case of INTERNAL HEMORRHOIDS |
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A 60-year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.
How should this patient be managed? |
- In ALL anorectal problems, cancer has to be ruled out first!
* PROCTOSIGMOIDOSCOPIC exam (digital rectal exam, anoscopy, and flexible sigmoidoscope)
- Once the diagnosis has been confirmed, internal hemorrhoids can be treated with rubber-band ligation - Prolapsed hemorrhoids require surgery |
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A 60-year old man known to have hemorrhoids complains of anal itching and discomfort, particularly toward the end of the day. He has mild perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort.
What is this? |
Internal hemorrhoids bleed but do not hurt whereas external hemorrhoids hurt but do not bleed, thus this is a case of EXTERNAL HEMORRHOIDS |
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A 60-year old man known to have hemorrhoids complains of anal itching and discomfort, particularly toward the end of the day. He has mild perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort.
How should this patient be managed? |
- In ALL anorectal problems, cancer has to be ruled out first!
* PROCTOSIGMOIDOSCOPIC exam (digital rectal exam, anoscopy, and flexible sigmoidoscope)
- Once the diagnosis has been confirmed, external hemorrhoids require surgery
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A 23-year old woman describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having BMs and when she finally does, the stools are hard and even more painful. Physical exam cannot be done, as she refuses to allow anyone to even draw apart her buttocks to look at the anus for fear of precipitating the pain.
What is this? |
Anal fissure |
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A 23-year old woman describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having BMs and when she finally does, the stools are hard and even more painful. Physical exam cannot be done, as she refuses to allow anyone to even draw apart her buttocks to look at the anus for fear of precipitating the pain.
How should this patient be managed? |
- All anorectal problems require ruling out cancer!! - Exam under anesthesia is the correct answer
- Medical management includes stool softeners and topical agents - A tight sphincter is believed to cause and perpetuate the problem, and injections with paralyzing agents (eg, Botox) have been proposed
- If it gets to surgery, lateral internal sphincterotomy is the operation of choice! |
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A 28-year old man is brought to the office by his mother. Beginning 4 months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, and in fact the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures, and fistulas all around the anus, with purulent discharge. There are no palpable masses.
What is this? |
The perianal area has fantastic blood supply and heals beautifully even though feces bathe the wounds. When these wounds do NOT heal, you must immediately think of CROHN'S DISEASE! |
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A 28-year old man is brought to the office by his mother. Beginning 4 months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, and in fact the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures, and fistulas all around the anus, with purulent discharge. There are no palpable masses.
How should this patient be managed? |
You still have to rule out malignancy (anal cancer does not heal either if not completely excised)!
A proper exam with biopsies is needed. Specimens should confirm Crohn's. |
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A 44-year old man shows up in the ER at 11 pm with exquisite perianal pain. He cannot sit down, reports that BMs are very painful, and has been having chills and fevers. Physical exam shows a hot, tender, red, fluctuant mass between the anus and ischial tuberosity.
What is this? |
Ischiorectal absess |
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A 44-year old man shows up in the ER at 11 pm with exquisite perianal pain. He cannot sit down, reports that BMs are very painful, and has been having chills and fevers. Physical exam shows a hot, tender, red, fluctuant mass between the anus and ischial tuberosity.
How should this patient be managed? |
Treatment for all abscesses is drainage. Cancer also has to be ruled out. The best option would be one that offers examination under anesthesia with I&D. If the patient is diabetic, I&D would have to be followed by very close in-hospital follow-up. |
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A 62-year old man complains of perianal discomfort and reports that there are fecal streaks soiling his underwear. Four months ago he had a perianal opening in the skin, and a cordlike tract can be palpated going from the opening toward the inside of the canal. Brownish purulent discharge can be expressed from the tract.
What is this? |
Fistula in ano |
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A 62-year old man complains of perianal discomfort and reports that there are fecal streaks soiling his underwear. Four months ago he had a perianal opening in the skin, and a cordlike tract can be palpated going from the opening toward the inside of the canal. Brownish purulent discharge can be expressed from the tract.
How should this patient be managed? |
First rule out cancer with proctosigmoidoscopy (necrotic tumors can drain).
Then schedule an elective fistulotomy. |
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A 55-year old HIV-positive man has a fungating mass out of the anus and rock-hard enlarged lymph nodes in both groins. He has lost a lot of weight, and looks emaciated and ill.
What is this? |
Squamous cell carcinoma of the anus |
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A 55-year old HIV-positive man has a fungating mass out of the anus and rock-hard enlarged lymph nodes in both groins. He has lost a lot of weight, and looks emaciated and ill.
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- Diagnosis: biopsy of the fungating mass - Treatment: nigro protocol of pre-op chemo and radiation followed by surgery in most cases |
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A 33-year old man vomits a large amount of bright red blood.
What is this? |
You can already tell the territory where the bleeding is taking place; from the tip of the nose to the ligament of Treitz |
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A 33-year old man vomits a large amount of bright red blood.
How should this patient be managed? |
Don't forget to look at the mouth and nose and then proceed with upper GI endoscopy |
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A 33-year old man has had three large BMs that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic and pale, and has a BP of 90/70 and a pulse rate of 110.
How should this patient be managed? |
Something needs to be done to define the area from which he is bleeding: with the available information, it could be from anywhere in the GI tract.
Fortunately he seems to be bleeding RIGHT NOW, thus the first diagnostic test is to place an NG tube and aspirate after you have looked in the nose and mouth. |
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A 33-year old man has had three large BMs that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic and pale, and has a BP of 90/70 and a pulse rate of 110. An NG tube returns copious amounts of bright red blood.
What is this? |
The area has been defined (tip of nose to ligament of Treitz). Proceed with endoscopy! |
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A 33-year old man has had three large BMs that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic and pale, and has a BP of 90/70 and a pulse rate of 110. An NG tube returns with clear, green fluid without blood.
What is this? |
If there is bile in the aspirate you would have exonerated the area down to the ligament of Treitz - provided you are sure the patient is bleeding NOW --> therefore the patient is bleeding from somewhere DISTAL to the ligament of Treitz
- If bleeding >2 ml/min --> Angiogram - If bleeding <0.5 ml/min --> Colonoscopy - If bleeding 0.5-2 ml/min --> Tagged Red-Cell Study
- Some would do the tagged red-cell study regardless of estimated rate of bleeding |
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A 72-yea old man has three large BMs that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale but has normal vitals. An NG tube returns clear, green fluid without blood.
What is this? |
Clear aspirate is meaningless because he is not bleeding right now. So the bleeding territory could be from tip of nose to anal canal.
3/4 of bleeding is upper and virtually all cases of lower GI bleeding are diseases of the elderly (diverticulitis, polyps, cancer, angiodysplasia) |
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A 72-yea old man has three large BMs that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale but has normal vitals. An NG tube returns clear, green fluid without blood.
How should this patient be managed? |
Angiography is NOT the first choice for slow bleeding or bleeding that has stopped. Even the proponents of radionuclide studies don't have much hope if the patient bled 3 days ago.
**The best choice is endoscopies - both upper and lower |
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A 7-year old boy passes a large bloody BM.
What is this? |
In this age group, Meckel diverticulum leads the list |
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A 7-year old boy passes a large bloody BM.
How should this patient be managed? |
By radioactively labeled technetium scan (not the one that tags RBCs, but the one that identifies gastric mucosa) |
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A 41-year old man has been in the ICU for 2 weeks being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.
What is this? |
Stress ulcer |
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A 41-year old man has been in the ICU for 2 weeks being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.
How should this patient be managed? |
It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antacids, or both
Once the bleeding takes place, the diagnosis is made as usual with endoscopy
Treatment will be difficult (start with endoscopic attempts - laser and such) but it may require angiographic embolization of the left gastric artery |
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A 59-year old man arrives in the ER at 2 am accompanied by his wife who is wearing curlers on her head and a robe over her nightgown. He has abdominal pain that began suddenly about 1 hour ago, and is now generalized, constant, and extremely severe. He lies motionless on the stretcher, is diaphoretic, and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.
What is this? |
Definitely an ACUTE ABDOMEN. Time and circumstances attest to the severity of the rapid onset of his problem. Physical findings are impressive. He has generalized acute peritonitis.
Best bet is perforated peptic ulcer - but we do not need to prove that. |
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A 59-year old man arrives in the ER at 2 am accompanied by his wife who is wearing curlers on her head and a robe over her nightgown. He has abdominal pain that began suddenly about 1 hour ago, and is now generalized, constant, and extremely severe. He lies motionless on the stretcher, is diaphoretic, and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.
How should this patient be managed? |
Acute abdomen does not require a precise diagnosis to proceed with surgical exploration. Lower lobe pneumonia and MI have to be ruled out with a CXR and ECG, and it would be nice to have a plain x-ray or CT of abdomen and a normal lipase.
The best answer of this vignette should be prompt emergency EX LAP |
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A 62-year old man with cirrhosis of the liver and ascites presents with generalized abdominal pain that started 12 hours ago. he now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.
What is this? |
Peritonitis in the cirrhotic with ascites or the child with nephrosis and ascites, could be PRIMARY PERITONITIS
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A 62-year old man with cirrhosis of the liver and ascites presents with generalized abdominal pain that started 12 hours ago. he now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.
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- Diagnosis: cultures of the ascitic fluid will yield a single organism - Treatment: appropriate antibiotics; do not need surgery as in primary peritonitis |
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A 43-year old man develops excruciating abdominal pain at 8:18 pm. When seen in the ER at 8:50 pm he has a rigid abdomen, lies motionless on the exam table, has no bowel sounds, and is obviously in great pain, which he describes as CONSTANT. X-ray shows free-air under the diaphragm.
What is this? |
Acute abdomen plus perforated viscus equals perforated duodenal ulcer in most cases.
Although this case exaggerates the sudden onset by giving the exact minutes, vignettes of perforated peptic ulcer will have a pretty sharp time of onset. |
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A 43-year old man develops excruciating abdominal pain at 8:18 pm. When seen in the ER at 8:50 pm he has a rigid abdomen, lies motionless on the exam table, has no bowel sounds, and is obviously in great pain, which he describes as CONSTANT. X-ray shows free-air under the diaphragm.
How should this patient be managed? |
Emergency exploratory laparotomy |
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A 44-year old alcoholic man presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of 2 hours. The pain is constant, radiates straight through to the back, and is accompanied by nausea, vomiting, and retching. He had a similar episode 2 years ago, for which he required hospitalization.
What is this? |
Acute pancreatitis |
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A 44-year old alcoholic man presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of 2 hours. The pain is constant, radiates straight through to the back, and is accompanied by nausea, vomiting, and retching. He had a similar episode 2 years ago, for which he required hospitalization.
How should this patient be managed? |
- Diagnosis: serum and urinary amylase and lipase; CT scan will follow if diagnosis is unclear or in a day or two if there is no improvement - Treatment: NPO, NG suction, IV fluids |
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A 43-year old obese mother of six children has severe RUQ abdominal pain that began 6 hours ago. The pain was colicky at first, radiated to the right shoulder and around toward the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding, and rebound in the RUQ. Her temp is 101 F, and she has WBC count of 16,000. She has had similar episodes of pain in the past brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anti-cholinergic meds.
What is this? |
Acute cholecystitis |
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A 43-year old obese mother of six children has severe RUQ abdominal pain that began 6 hours ago. The pain was colicky at first, radiated to the right shoulder and around toward the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding, and rebound in the RUQ. Her temp is 101 F, and she has WBC count of 16,000. She has had similar episodes of pain in the past brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anti-cholinergic meds.
How should this patient be managed? |
- Diagnosis: U/S should be first choice; if equivocal a HIDA scan (radionuclide excretion scan) - Treatment: medical management in most cases will "cool down" the process; surgery will follow |
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A 52-year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria.
What is this? |
Ureteral colic (included here for differential diagnosis) |
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A 52-year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria.
How should this patient be treated? |
CT scan |
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A 59-year old woman has a history of three prior episodes of LLQ abdominal pain for which she was briefly hospitalized and treated with antibiotics. She began to feel discomfort 12 hours ago, and now she has constant LLQ pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.
What is this? |
Acute diverticulitis |
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A 59-year old woman has a history of three prior episodes of LLQ abdominal pain for which she was briefly hospitalized and treated with antibiotics. She began to feel discomfort 12 hours ago, and now she has constant LLQ pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.
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- Diagnosis: CT scan - Treatment: medical for acute attack (antibiotics, NPO) but elective sigmoid resection is advisable for recurrent disease (like this woman is having); percutaneous drainage of abscess is indicated if one is present; emergency surgery (resection or colostomy) may be needed if she gets worse or does not respond to treatment |
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An 82-year old man develops severe abdominal distension, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the RUQ and tapers toward the LLQ with the shape of a parrot's beak.
What is this? |
Volvulus of the sigmoid |
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An 82-year old man develops severe abdominal distension, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the RUQ and tapers toward the LLQ with the shape of a parrot's beak.
How should this patient be managed? |
Proctosigmoidoscopy will relieve the obstruction, and a rectal tube should be left in place
Eventually, surgery to prevent recurrences could be considered |
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A 79-year old man with AFib develops an acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-rays show distended small bowel and distended colon up to the middle of the transverse colon.
What is this? |
Acute abdomen in an elderly person with AFib brings to mind EMBOLIC OCCLUSION of MESENTERIC VESSELS.
Acidosis frequently ensues, and blood in the stool is often seen. Unfortunately not much can be done, as the bowel is usually dead.
Young, aggressive vascular surgeons would call for an angiogram to perform emergency embolectomy, assuming the case is seen very early before the bowel dies. |
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A 53-year old man with cirrhosis of the liver develops malaise, vague RUQ abdominal discomfort, and 20-pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha-fetoprotein is significantly elevated.
What is this? |
Cancer in the liver: alpha-fetoprotein goes with PRIMARY HEPATOMA |
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A 53-year old man with cirrhosis of the liver develops malaise, vague RUQ abdominal discomfort, and 20-pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha-fetoprotein is significantly elevated.
How should this patient be managed? |
- Diagnosis: CT scan w/ contrast to define location and extent of tumor - Treatment: Resection if a tumor-free anatomic segment can be left behind |
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A 53-year old man with cirrhosis of the liver develops malaise, vague RUQ abdominal discomfort, and 20-pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a R hemicolectomy for cancer of ascending colon. His carcinoembryonic antigen (CEA) had been within normal limits right after his hemicolectomy, but is now 10x normal.
What is this? |
Cancer in the liver: CEA goes with metastatic tumor from the colon |
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A 53-year old man with cirrhosis of the liver develops malaise, vague RUQ abdominal discomfort, and 20-pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a R hemicolectomy for cancer of ascending colon. His carcinoembryonic antigen (CEA) had been within normal limits right after his hemicolectomy, but is now 10x normal.
How should this patient be managed? |
- Diagnosis: CT scan w/ contrast to define location and extent of tumor - Treatment: Resection is done if there are no other metastases, it is surgically possible, and the primary tumor is relatively slow growing |
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A 24-year old woman develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a Hgb of 7 g/dl. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never missed taking them.
What is this? |
Bleeding from a ruptured HEPATIC ADENOMA, 2/2 to birth control pills |
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A 24-year old woman develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a Hgb of 7 g/dl. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never missed taking them.
How should this patient be managed? |
CT scan to confirm she is bleeding into the belly and to show the liver adenoma; surgery will follow |
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A 44-year old woman is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the RUQ. An U/S reveals a liver abscess.
What is this? How should this patient be managed? |
Not much of a diagnostic challenge here, but the issue is management. This is a PYOGENIC ABSCESS, it needs to be drained (radiology will do it percutaneously). |
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A 29-year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alk phos. U/S of the right upper abdominal area shows a normal biliary tree and an abscess in the liver.
What is this? |
Amebic abscess - very common in Mexico |
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A 29-year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alk phos. U/S of the right upper abdominal area shows a normal biliary tree and an abscess in the liver.
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Alone among abscesses, this one in most cases does NOT have to be drained, but can be effectively treated with METRONIDAZOLE
If patient improves promptly you know you are on the right track.
When serologies come back, the patient will be well and your diagnosis will be confirmed.
Don't fall for an option that suggests aspirating the pus and sending it for culture; you cannot grow ameba from the pus |
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A 42-year old woman is jaundiced. She has a total bilirubin of 6, and lab reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is 0. She has no bile in the urine.
What is this? |
Hemolytic jaundice (you know this because the bilirubin is all from indirect and none from direct) |
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A 42-year old woman is jaundiced. She has a total bilirubin of 6, and lab reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is 0. She has no bile in the urine.
How should this patient be managed? |
Figure out what is chewing up her RBCs |
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A 19-year old college student returns from a trip to Cancun, and 2 weeks later develops malaise, weakness, and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alk phos is mildly elevated, and the transaminases are very high!
What is this? |
Hepatocellular jaundice (viral hepatitis most likely) |
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A 19-year old college student returns from a trip to Cancun, and 2 weeks later develops malaise, weakness, and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alk phos is mildly elevated, and the transaminases are very high!
How should this patient be managed? |
Get serologies to confirm diagnosis and type of hepatitis |
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A patient with progressive jaundice that has been present for 4 weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alk phos was 2x the normal value 2 weeks ago, and now is about 6x the upper limit of normal.
What is this? |
Generic example of obstructive jaundice |
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A patient with progressive jaundice that has been present for 4 weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alk phos was 2x the normal value 2 weeks ago, and now is about 6x the upper limit of normal.
How should this patient be managed? |
U/S, looking for dilated intrahepatic ducts, possibly dilated extra hepatic ducts as well, and if we get lucky, a finding of gallstones |
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A 40-year old obese mother of five children presents with progressive jaundice, which she first noticed 4 weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alk phos is about 6x the upper limit of normal. She gives a history of multiple episodes of colicky RUQ abdominal pain, brought about by ingestion of fatty food.
What is this? |
Obstructive jaundice with a good chance of being caused by stones |
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A 40-year old obese mother of five children presents with progressive jaundice, which she first noticed 4 weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alk phos is about 6x the upper limit of normal. She gives a history of multiple episodes of colicky RUQ abdominal pain, brought about by ingestion of fatty food.
How should this patient be managed? |
- Start with U/S - After that you can do ERCP, which could also be used to remove the stones from the common duct - Cholecystectomy will eventually need to be performed |
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A 66-year old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally invasive elevated transaminases. The alk phos is about 6x the upper limit of normal. He has lost 10 lbs over the past 2 months, but is otherwise asymptomatic. An U/S shows dilated intrahepatic ducts, dilated extra hepatic ducts, and a very distended, thin-walled gallbladder.
What is this? |
- Malignant obstructive jaundice - "Silent" obstructive jaundice is more likely to be caused by tumor (although most patients with pancreatic tumor have dull constant pain) - A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick-walled and non pliable |
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A 66-year old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally invasive elevated transaminases. The alk phos is about 6x the upper limit of normal. He has lost 10 lbs over the past 2 months, but is otherwise asymptomatic. An U/S shows dilated intrahepatic ducts, dilated extra hepatic ducts, and a very distended, thin-walled gallbladder.
How should this patient be managed? |
- You already have the U/S, next move is CT scan - Follow with ERCP if the CT is not diagnostic |
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A 66-year old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alk phos is about 6x the upper limit of normal. He is otherwise asymptomatic. An U/S shows dilated intrahepatic ducts, dilated extra-hepatic ducts, and a very distended, thin-walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct.
What is this? |
Malignant, but lucky: probably cholangiocarcinoma at the lower end of the common duct |
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A 66-year old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alk phos is about 6x the upper limit of normal. He is otherwise asymptomatic. An U/S shows dilated intrahepatic ducts, dilated extra-hepatic ducts, and a very distended, thin-walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct.
How should this patient be managed? |
- Get brushings of the common duct for cytologic diagnosis of cholangiocarcinoma - Treatment: Pancreatoduodenectomy (Whipple operation) |
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A 64-year old woman presents with progressive jaundice, which she first noticed 2 weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated transaminases. The alk phos is about 10x the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. An U/S shows dilated intrahepatic ducts, dilated extra hepatic ducts, and a very distended, thin walled gallbladder.
What is this? |
Again malignant, but lucky. The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an AMPULLA CARCINOMA, another malignancy that can be cured with radical surgery. |
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A 64-year old woman presents with progressive jaundice, which she first noticed 2 weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated transaminases. The alk phos is about 10x the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. An U/S shows dilated intrahepatic ducts, dilated extra hepatic ducts, and a very distended, thin walled gallbladder.
How should this patient be managed? |
- Endoscopy - Treat with radical surgery |
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A 56-year old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally invasive transaminases. The alk phos is about 8x the upper limit of normal. He has lost 20 lbs over the past 2 months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. An U/S shows dilated intrahepatic ducts, dilated extra hepatic ducts, and a very distended, thin-walled gallbladder.
What is this? |
Bad news - cancer of the head of the pancreas (terrible prognosis) |
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A 56-year old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally invasive transaminases. The alk phos is about 8x the upper limit of normal. He has lost 20 lbs over the past 2 months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. An U/S shows dilated intrahepatic ducts, dilated extra hepatic ducts, and a very distended, thin-walled gallbladder.
How should this patient be managed? |
CT scan, which may show the mass in the head of the pancreas; if it does not, do ERCP, which will probably show obstruction of both common duct and pancreatic duct |
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A white, obese 40-year old mother of five children gives a history of repeated episodes of RUQ abdominal pain brought about by the ingestion of fatty foods, and relieved by administration of anti-cholinergic meds. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. Physical exam is unremarkable.
What is this? |
Gallstones, with biliary colic |
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A white, obese 40-year old mother of five children gives a history of repeated episodes of RUQ abdominal pain brought about by the ingestion of fatty foods, and relieved by administration of anti-cholinergic meds. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. Physical exam is unremarkable.
How should this patient be managed? |
U/S, elective cholecystectomy will follow |
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A 43-year old mother of six children has severe RUQ abdominal pain that began 6 hours ago. The pain was colicky at first, radiated to the right shoulder and around toward the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding, and rebound in the RUQ. Her temp is 101 F, and she has a WBC count of 12,000. LFTs are normal.
What is this? |
Acute Cholecystitis |
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A 73-year old obese mother of six children has severe RUQ pain that began 3 days ago. The pain was colicky at first but has been constant for the past 2.5 days. She has tenderness to deep palpation, muscle guarding, and rebound in the RUQ. She has temperature spikes of 104-105 F, with chills. Her WBC count is 22,000 with a shift to the left. Her bilirubin is 5, and she has alk phos of 2000 (about 20x normal).
What is this? |
Acute Ascending Cholangitis |
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A 73-year old obese mother of six children has severe RUQ pain that began 3 days ago. The pain was colicky at first but has been constant for the past 2.5 days. She has tenderness to deep palpation, muscle guarding, and rebound in the RUQ. She has temperature spikes of 104-105 F, with chills. Her WBC count is 22,000 with a shift to the left. Her bilirubin is 5, and she has alk phos of 2000 (about 20x normal).
How should this patient be managed? |
- Diagnosis: already clear, U/S might confirm dilated ducts - Treatment: emergency - IV antibiotics plus emergency decompression of the biliary tract (ERCP is first choice, but percutaneous transhepatic cholangiogram (PTC) is another option with surgery as a distant third option) |
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A white, obese 40-year old mother of five children gives a history of repeated episodes of RUQ pain brought about by ingestion of fatty foods, and relieved by administration of anticholinergic meds. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain and the pain lasted longer than normal. She has mild tenderness to palpation in the epigastrium and RUQ. Lab determination show a bilirubin of 3.5, an alk phos 5x normal, and serum amylase 3x normal.
What is this? |
She passed a common duct stone and had a transient episode of cholangitis (the shaking chill, high phosphatase) and a bit of biliary pancreatitis (high amylase) |
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A white, obese 40-year old mother of five children gives a history of repeated episodes of RUQ pain brought about by ingestion of fatty foods, and relieved by administration of anticholinergic meds. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain and the pain lasted longer than normal. She has mild tenderness to palpation in the epigastrium and RUQ. Lab determination show a bilirubin of 3.5, an alk phos 5x normal, and serum amylase 3x normal.
How should this patient be managed? |
- Start with U/S to confirm presence of gallstones - If she continues to improve, elective cholecystectomy will follow - If she deteriorates, she may have stone still impacted at ampulla of Vater and may need ERCP and sphincterotomy to extract it |
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A 33-year old alcoholic man shows up in ER with epigastric and mid abdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant and very severe and radiates straight through to the back. He vomited 2x early on, but since then has continued to have retching. He has tenderness and some muscle guarding in the upper abdomen, is afebrile, and has mild tachycardia. Serum amylase is 1200 and hematocrit is 52%.
What is this? |
Acute Edematous Pancreatitis |
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A 33-year old alcoholic man shows up in ER with epigastric and mid abdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant and very severe and radiates straight through to the back. He vomited 2x early on, but since then has continued to have retching. He has tenderness and some muscle guarding in the upper abdomen, is afebrile, and has mild tachycardia. Serum amylase is 1200 and hematocrit is 52%.
How should this patient be managed? |
Put the pancreas at rest: NPO, NG suction, IV fluids |
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A 56-year old alcoholic man is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight through to the back, and is extremely severe. He has a serum amylase of 800, hematocrit of 40%, WBC count of 18,000, blood glucose of 150, serum calcium of 6.5. He is given IV fluids and kept NPO with NG suction. By the next morning, his Hct dropped to 30%, serum calcium has remained below 7 despite calcium administration, his BUN has gone up to 32, and he has developed metabolic acidosis and a low arterial PO2.
What is this? |
He has hemorrhagic pancreatitis
He has 8 of Ranson's criteria, predicting 80-100% mortality! |
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A 56-year old alcoholic man is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight through to the back, and is extremely severe. He has a serum amylase of 800, hematocrit of 40%, WBC count of 18,000, blood glucose of 150, serum calcium of 6.5. He is given IV fluids and kept NPO with NG suction. By the next morning, his Hct dropped to 30%, serum calcium has remained below 7 despite calcium administration, his BUN has gone up to 32, and he has developed metabolic acidosis and a low arterial PO2.
How should this patient be managed? |
Very intensive support will be needed, but the common pathway to death from complications of hemorrhagic pancreatitis frequently is by way of pancreatic abscesses that need to be drained as soon as they appear. Serial CT scans will be required. |
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A 57-year old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the ICU for 1 week, required chest tubes for pleural effusion, and was on a respiratory for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease, he begins to spike fever and to demonstrate leukocytosis.
What is this? |
Pancreatic abscess |
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A 57-year old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the ICU for 1 week, required chest tubes for pleural effusion, and was on a respiratory for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease, he begins to spike fever and to demonstrate leukocytosis.
How should this patient be managed? |
- Diagnosis: CT scan - Treatment: Drainage and Imipenem or Meropenem |
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A 49-year old alcoholic man presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen and actually hard to define. He was discharged from he hospital 5 weeks ago, after successful treatment for acute pancreatitis.
What is this? |
Pancreatic Pseudocyst |
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A 49-year old alcoholic man presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen and actually hard to define. He was discharged from he hospital 5 weeks ago, after successful treatment for acute pancreatitis.
How should this patient be managed? |
- You could diagnose with U/S, but CT scan is probably best - Small cysts (<6cm) that are not present too long (<6 weeks) can be watched waiting for spontaneous resolution - Bigger or older cysts can have serious complications (rupture, bleeding) and need intervention - Internal surgical derivation (cystogastrostomy or cystojejunostomy) used to be the treatment - Radiologically guided external drainage then became an option, and the latest and best (if feasible) is ENDOSCOPIC CYSTOGASTROSTOMY |
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A disheveled, malnourished individual shows up in the ER requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back, that he says he has had for several years. He has diabetes, steatorrhea, and calcifications in the upper abdomen in a plain x-ray.
What is this? |
Chronic pancreatitis |
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A disheveled, malnourished individual shows up in the ER requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back, that he says he has had for several years. He has diabetes, steatorrhea, and calcifications in the upper abdomen in a plain x-ray.
How should this patient be managed? |
- Stopping the alcohol intake is first step - Replacement of pancreatic enzymes will relieve the pain, but if they do not, the pain will be very difficult to eradicate - If further diagnostic testing is requested, pick ERCP |
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A 9-month baby girl is brought in because she has an umbilical hernia. The defect is 1 cm in diameter, and the contents are freely reducible.
How should this patient be managed? |
Although we routinely recommend elective surgical repair of all hernias (to prevent ghastly complication of strangulation), there are some exceptions. This is one.
Umbilical hernias in babies younger than the age of 2 years may still close spontaneously. Only observation is needed here. |
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An 18-year old man has a routine physical exam as part of his college registration, and the exam reveals that he has a right inguinal hernia. The external inguinal ring is about 2.5 cm in diameter, and a hernial bulge can be easily seen and felt going down into his scrotum when he is asked to strain. He is completely asymptomatic and was not even aware of the presence of the hernia.
How should this patient be managed? |
Elective surgical repair is in order. Even though he is asymptomatic, he should not be exposed to the risk of bowel strangulation. The hernia is probably indirect, and either open or laparoscopic (preferably extraperitoneal) approach can be used. |
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A 72-year old farmer is forced by his insurance company to have a physical exam to be issued a life insurance policy. He has been healthy all his life, and "has never been to the doctor". At the exam it is found that he has a large, left inguinal hernia that reaches down into the scrotum. Bowel sounds can be easily heard over it. The hernia is not reducible, and he says that many years ago he used to be able to "push it back," but for the last 10-20 years he has not been able to do so.
How should this patient be managed? |
A hernia that cannot be pushed back in (reduced) is incarcerated, and one that has compromised blood supply is strangulated - which is an emergency.
If the hernia is newly incarcerated this is also an emergency, because one does not want to wait for overt signs of dead or compromised bowel before operating.
If he has been this way for 10-20 years, obviously bowel is still alive and well. Elective repair is still indicated, before he runs out of good luck! |
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An 18-year old woman has a firm, rubbery mass in the left breast that moves easily with palpation?
What is this? |
Fibroadenoma |
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An 18-year old woman has a firm, rubbery mass in the left breast that moves easily with palpation?
How should this patient be managed? |
- Underlying concern in all breast masses is cancer, and the best predictor of malignancy is age - At age 18, the chances of malignancy are very remote; thus the least invasive way to make the diagnosis is, in order, either FNA for cytology or U/S - U/S happens to be quite diagnostic for fibroadenomas (more so than for other conditions) - Reassurance alone would NOT be a good choice! - Do not order a mammogram either; at age 18 mammograms are useless (breast is too dense) - U/S is the only imaging technique suitable for a young breast - Once diagnosis is confirmed, excision is option
tl;dr: FNA or U/S --> confirm fibroadenoma --> excision is optional |
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A 14-year old girl has a firm, movable, rubbery mass in her left breast that was first noticed 1 year ago and has since grown to be about 6 cm in diameter.
What is this? |
Giant Juvenile Fibroadenoma |
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A 14-year old girl has a firm, movable, rubbery mass in her left breast that was first noticed 1 year ago and has since grown to be about 6 cm in diameter.
How should this patient be managed? |
- At age 14 chances of cancer are virtually zero; that avenue does not have to be explored - Rapid growth requires RESECTION to avoid cosmetic deformity |
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A 27-year old immigrant from Mexico has a 12 x 7 cm mass in her left breast. It has been present for 7 years, and has been slowly growing to its present size. The mass - firm, rubbery, completely movable - is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
What is this? |
Crystosarcoma phyllodes - a benign condition that can turn into an outright malignant sarcoma
(common in late 20s, grows over many years, may distort the breast) |
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A 27-year old immigrant from Mexico has a 12 x 7 cm mass in her left breast. It has been present for 7 years, and has been slowly growing to its present size. The mass - firm, rubbery, completely movable - is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
How should this patient be managed? |
After tissue diagnosis proceed with margin-free resection
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A 35-year old woman has a 10-year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to "come and go" at different times in the menstrual cycle. She now has a firm, round, 2-cm mass that has not gone away for 6 weeks.
What is this? |
Palpable cyst in fibrocystic disease (cystic mastitis, mammary dysplasia) |
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A 35-year old woman has a 10-year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to "come and go" at different times in the menstrual cycle. She now has a firm, round, 2-cm mass that has not gone away for 6 weeks.
How should this patient be managed? |
- Start with mammogram to see if there are other non-palpable lesions - Once we zero in on this lesion, tissue diagnosis (ie, biopsy) becomes impractical when there are lumps every month ** ASPIRATION of the cyst is the answer here (NOT FNA, this is aspiration of fluid to empty a cyst, not aspiration of a solid mass to get cells) - If the mass goes away and the fluid aspirated is clear, that's all - If the fluid is bloody it goes to cytology - If the mass does not go away or recurs she needs biopsy |
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A 34-year old woman has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses.
What is this? |
Intraductal Papilloma |
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A 34-year old woman has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses.
How should this patient be managed? |
- Old concern over cancer is the issue, and the way to detect cancer that is not palpable is with MAMMOGRAM - If mammogram is negative one may still wish to find and resect the intraductal papilloma to provide symptomatic relief - Resection can be guided by galactogram or done as a retroareolar exploration |
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A 26-year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis.
What is this? |
Sounds like an abscess!
However only lactating breasts are entitled to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise. |
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A 26-year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis.
How should this patient be managed? |
No point on doing a mammogram on a lactating breast (even if she were older)
I&D is the treatment for all abscesses
If an option includes drainage with biopsy of abscess wall, go for that one |
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A 49-year old woman has a firm, 2-cm mass in the right breast, which has been present for 3 months.
What is this? |
This could be anything. Age is best determinant for risk for cancer of the breast. If she had been 72, you go for cancer. At 22, you favor benign. |
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A 49-year old woman has a firm, 2-cm mass in the right breast, which has been present for 3 months.
How should this patient be managed? |
Mammographically guided multiple core biopsies are needed |
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A 34-year old woman in her fifth month of pregnancy reports a 3-cm firm, ill-defined mass in her right breast that has been present and growing for 3 months.
How should this patient be managed? |
- The diagnosis of possible breast cancer in the pregnant patient is done the same way as if she had not been pregnant - You can dot he mammogram and appropriate biopsies - The radiologist will probably want to use U/S to guide the biopsies - You do not need to terminate the pregnancy |
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A 69-year old woman has a 4-cm hard mass in the right breast with ill-defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted and has an "orange peel" appearance.
How should this patient be managed? |
- Classic presentation of breast cancer - Needs mammographically guided multiple core biopsies |
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A 69-year old woman has a 4-cm hard mass in the right breast with ill-defined borders, movable from the chest wall but not movable within the breast. The nipple became retracted 6 months ago.
How should this patient be managed? |
- Classic presentation of breast cancer - Needs mammographically guided multiple core biopsies |
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A 72-year old woman has a red, swollen breast. The skin over the area looks like an orange peel. She is not particularly tender, and it is debatable whether the area is hot or not. She has no fever or leukocytosis.
How should this patient be managed? |
- Classic presentation of breast cancer - Needs mammographically guided multiple core biopsies |
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A 62-year old woman has an eczematoid lesion in the areola. It has been present for 3 months, and it looks to her like some kind of skin condition that has not improved or gone away with a variety of lotions and ointments.
How should this patient be managed? |
- Classic presentation of breast cancer - Needs mammographically guided multiple core biopsies |
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A 42-year old woman hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and 1 week later the lump is still there. She has a 3-cm hard mass deep inside the affected breast, and some superficial ecchymosis over the area.
What is this? |
Remember!!! This is cancer until proven otherwise! Trauma often brings the area to the attention of the patient - but is not the cause of the lump! |
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A 42-year old woman hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and 1 week later the lump is still there. She has a 3-cm hard mass deep inside the affected breast, and some superficial ecchymosis over the area.
How should this patient be managed? |
Needs mammographically guided multiple core biopsies (must rule out cancer!!!) |
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A 58-year old woman discovers a mass in her right axilla. She has a discrete, hard, movable 2-cm mass. Physical exam of her breast is negative, and she has no enlarged lymph nodes elsewhere.
What is this? |
Tough, but another potential presentation for breast cancer. In a younger patient you would think of lymphoma. It could still be lymphoma on her. She needs a mammogram (we are now looking for an occult primary), and the node will eventually have to be biopsied. |
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A 58-year old woman discovers a mass in her right axilla. She has a discrete, hard, movable 2-cm mass. Physical exam of her breast is negative, and she has no enlarged lymph nodes elsewhere.
How should this patient be managed? |
She needs a mammogram (we are now looking for an occult primary), and the node will eventually have to be biopsied. |
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A 60-year old woman has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present 2 years ago on a previous mammogram.
How should this patient be managed? |
This is a description of a malignant radiologic image - we need TISSUE BIOPSY (core) |
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A 44-year old woman has a 2-cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable, and her breast is of normal, rather generous size. She has no palpable axillary nodes, and the mammogram showed no other lesions.
How should this patient be managed? |
- Treatment of operable breast cancer begins with SURGERY - With a small tumor far away from the nipple, the standard option is segmental resection (lumpectomy) and axillary node sampling to help determine the need for adjuvant systemic therapy - Why go after the axillary nodes when they are not palpable? Because palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis - Afterword, RADIATION therapy has to be given to the remaining breast (otherwise, lumpectomy would have an unacceptably high rate of local recurrence) |
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A 62-year old woman has a 4-cm hard mass under the nipple and areola of her smallish left breast. A core biopsy has diagnosed infiltrating ductal carcinoma. There are no palpable axillary nodes, and the mammogram shows no other lesions.
How should this patient be managed? |
- Lumpectomy is an option only when the tumor is small (in absolute terms and in relation to the breast) and located where most of the breast can be spared - A modified radical mastectomy (MRM) is the best choice here - Axillary sampling of sentinel nodes is also required - Radiation is not needed when the whole breast is removed - The old (unmodified) radical mastectomy is no longer done |
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A 44-year old woman has a 2-cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows lobular cancer.
How should this patient be managed? |
Lobular has a higher incidence of bilaterality (but not enough to justify bilateral mastectomy); treat the same as infiltrating ductal carcinoma |
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A 44-year old woman has a 2-cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows medullary cancer of the breast.
How should this patient be managed? |
All variants of invasive cancer have a little better prognosis than infiltrating ductal cancer and they are all treated the same |
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A 52-year old woman has a suspicious area on mammogram. Multiple radiologically guided core biopsies show ductal carcinoma in situ.
How should this patient be managed? |
- No axillary sampling is needed if this lesion is confined to one quadrant - Lumpectomy and radiation should be performed - If there are multicentric lesions all over the breast, simple total mastectomy is needed, and sentinel node biopsy should be done |
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A 32-year old woman in the seventh month of pregnancy is found to have a 2-cm mass in the left breast. Mammogram shows no other lesions and core biopsy reveals infiltrating ductal carcinoma.
How should this patient be managed? |
- Pregnancy imposes very little limitations to our handling of breast cancer - The only no-no's are no radiation therapy during pregnancy, and no chemo during the first trimester - Termination of the pregnancy is not needed |
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A 44-year old woman shows up in the ER because she is "bleeding from the breast". Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the mass has been present for only "a few weeks," but a relative indicates that it has been there at least 2 years, maybe longer.
How should this patient be managed? |
- Obviously a far advanced cancer of the breast - Tissue diagnosis is still needed, and either a core biopsy or an incisional biopsy is in order - This is inoperable, and incurable as well, but palliation can be offered - Chemo is the first line of treatment perhaps accompanied by radiation - The tumor may shrink enough to become operable for palliation |
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A 37-year old woman has a lumpectomy and axillary sentinel node sampling for a 3-cm infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in both of the sentinel axillary nodes that were removed. The tumor is positive for estrogen and progesterone receptors.
How should this patient be managed? |
- Very rarely is surgery alone sufficient to cure breast cancer - Virtually all patients are given subsequent adjuvant systemic therapy; need for it is underscored by the finding of involved axillary nodes - CHEMO is mandatory here, followed by RADIATION (because she had a lumpectomy) and finally, HORMONAL THERAPY (which given her age should be tamoxifen) |
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A 66-year old woman has an MRM for infiltrating ductal carcinoma of the breast. The pathologist reports that the tumor measures 1 cm in diameter and that 1 of 2 sentinel axillary nodes removed are positive for metastasis. The tumor is estrogen and progesterone receptor positive.
How should this patient be managed? |
Hormonal therapy of choice in post-menopausal woman is ANASTROZOLE; this should follow CHEMO in this case or it could be the only treatment if her general health precludes the use of chemo |
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A 44-year old woman complains bitterly of severe headaches that have been present for several weeks and have not responded to the usual OTC headache remedies. She is 2 years post-op from MRM for T3 N2 M0 cancer of the breast, and she had several courses of post-op chemotherapy, which she eventually discontinued because of the side effects.
How should this patient be managed? |
Classic: severe headache in someone who a few years ago had extensive cancer of the breast means brain metastases until proven otherwise.
Don't get hung up on the TNM classification; if the numbers are not 1 for the tumor and 0 for the nodes and metastases, the tumor is bad.
Do MRI of the brain and use high-dose steroids and radiation! |
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A 39-year old woman completed her last course of post-op adjuvant chemo for breast cancer 6 months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well-circumscribed areas in the thoracic and lumbar spine.
How should this patient be managed? |
This patient has bone metastases from breast cancer until proven otherwise!
MRI for diagnosis
Local radiation to the metastases may help, and a variety of ortho supports can be used to prevent collapse of the vertebral pedicles |
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A 62-year old woman was drinking her morning cup of coffee at the same time she was applying her makeup, and she noticed int he mirror that there was a lump in the lower part of the neck, visible when she swallowed. She consults you for this, and on physical exam you ascertain that she indeed has a prominent, 2-cm mass on the left lobe of her thyroid as well as two smaller masses on the right lobe. They are all soft, and she has no palpable lymph nodes in the neck.
How should this patient be managed? |
- Most thyroid nodules are benign, and surgical removal to ascertain the diagnosis is a big operation - thus surgery has to be reserved for selected cases - Worrisome features include: young, male, single nodule, history of radiation to the neck, solid mass on U/S, and cold nodule on scan - In centers with sufficient experience, the last two tests are omitted in preference for FNA and cytology - This case does not sound malignant, but you cannot be sure * If given the option among answers, go for FNA |
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A 21-year old man is found on routine physical exam to have a single 2-cm nodule in the thyroid gland. His thyroid function tests are normal. An FNA is read as indeterminate.
How should this patient be managed? |
Surgery is done for the FNAs that are read as malignant and those that are indeterminate |
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A 32-year old woman has a thyroid lobectomy done for a 2-cm mass that had been reported on FNA as a "follicular neoplasm, not otherwise specified". The specimen is given for frozen section to a pathologist with a great deal of experience in thyroid disease and in the reading of frozen sections. The intra-operative diagnosis is follicular cancer.
How should this patient be managed? |
Total thyroidectomy |
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An automated blood chemistry panel done during the course of a routine medical exam indicates than an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between 10.5-12.6. Serum phosphorus is low.
What is this? |
Parathyroid adenoma |
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An automated blood chemistry panel done during the course of a routine medical exam indicates than an asymptomatic patient has a serum calcium of 12.1 in a lab where the upper limit of normal is 9.5. Repeated determinations are consistently between 10.5-12.6. Serum phosphorus is low.
How should this patient be managed? |
Most cases of hypercalcemia are caused by metastatic cancer, but that would not be the case on asymptomatic people
Your next move is to check PTH and sestamibi scan to localize the adenoma. Surgery will follow. |
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A 32-year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (She had not been aware of such diagnosis beforehand). It is also ascertained that she has been amenorrheic and shaving for the past couple of years. She has gross centripetal obesity with moon facies and buffalo hump and thin, bruised extremities. A picture from 3 years ago shows a person of very different, more normal appearance.
What is this? |
Cushing: - Appearance is so typical that you will probably be given before and after photos on the test with an accompanying brief vignette - The presenting symptom may be any one of those listed |
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A 32-year old woman is admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic and to have osteoporosis. (She had not been aware of such diagnosis beforehand). It is also ascertained that she has been amenorrheic and shaving for the past couple of years. She has gross centripetal obesity with moon facies and buffalo hump and thin, bruised extremities. A picture from 3 years ago shows a person of very different, more normal appearance.
How should this patient be managed? |
- Start with overnight dose dexamethasone suppression test: if she suppresses at a low dose, she is an obese, hairy woman but she does not have disease; if she does not suppress at the low dose, verify that 24-hour urine free cortisol is elevated, and then go to high-dose suppression tests - If she suppresses with a high dose, do an MRI of the head to look for the pituitary microadenoma, which will be removed by the transnasal, trans-sphenoidal route - If she does not suppress with a high dose, do a CT or MRI of adrenals looking for adenoma there |
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A 28-year old woman has virulent peptic ulcer disease. Extensive medical management including eradication of H. pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea.
What is this? |
Gastrinoma (Zollinger-Ellison) |
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A 28-year old woman has virulent peptic ulcer disease. Extensive medical management including eradication of H. pylori fails to heal her ulcers. She has several duodenal ulcers in the first and second portions of the duodenum. She has watery diarrhea.
How should this patient be managed? |
- Start by measuring serum gastrin. If the value is not clearly normal or abnormal, a secretin stimulation test is added. - Later CT scans (with vascular and GI contrast) of the pancreas and nearby areas to find the tumor - Surgery to remove it |
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A second-year medical student is hospitalized for a neuro work-up for a seizure disorder of recent onset. During one of the convulsions, it is determined that his blood sugar is extremely low. Further workup shows that he has high levels of insulin in the blood with low levels of C-peptide.
What is this? |
Exogenous administration of insulin; if the C-peptide had been high along with the insulin level, the diagnosis would have been insulinoma.
Had it been a baby with high insulin levels and low blood sugar, nesidioblastosis! |
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A second-year medical student is hospitalized for a neuro work-up for a seizure disorder of recent onset. During one of the convulsions, it is determined that his blood sugar is extremely low. Further workup shows that he has high levels of insulin in the blood with low levels of C-peptide.
How should this patient be managed? |
In this case, psych eval and counseling (he is faking the disease to avoid taking the USMLE)
If it had been insulinoma, CT scan (with vascular and GI contrast) looking for the tumor in the pancreas, to be subsequently removed surgically.
The babies with nesidioblastosis need 95% pancreatectomy. |
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A 48-year old woman has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kind of "herbs and unguents." She is thin and has mild stomatitis and mild diabetes mellitus.
What is this? |
Glucagonoma |
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A 48-year old woman has had severe, migratory necrolytic dermatitis for several years, unresponsive to all kind of "herbs and unguents." She is thin and has mild stomatitis and mild diabetes mellitus.
How should this patient be managed? |
- Determine glucagon levels - Eventually CT scan (with vascular and GI contrast) looking for the tumor in the pancreas - Surgery will follow - If inoperable, somatostatin can help symptomatically, and streptozocin is the indicated chemo agent |
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A 45-year old woman comes into your office for a regular check-up. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office 3 years ago, her BP was normal. Lab studies show a serum sodium of 144 mEq/L, a serum bicarb of 28 mEq/L, and a serum K+ of 2.1 mEq/L. The woman is taking no meds of any kind.
What is this? |
Hyperaldosteronism; possibly adenoma |
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A 45-year old woman comes into your office for a regular check-up. On repeated determinations you confirm the fact that she is hypertensive. When she was in your office 3 years ago, her BP was normal. Lab studies show a serum sodium of 144 mEq/L, a serum bicarb of 28 mEq/L, and a serum K+ of 2.1 mEq/L. The woman is taking no meds of any kind.
How should this patient be managed? |
- Start with determination of aldosterone and renin levels - If confirmatory (high aldosterone, low renin), proceed with determinations lying down and sitting up to differentiate hyperplasia (appropriate respond to postural changes - not surgical) from adenoma (no response or wrong response to postural changes - surgical)
- Treat hyperplasia with Aldactone - Manage adenoma with imaging studies (CT or MRI) and surgery |
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A thin, hyperactive 38-year old woman is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration, and pallor, but by the time she gets to her doctor's office she checks out normal in every respect.
What is this? |
Pheochromocytoma |
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A thin, hyperactive 38-year old woman is frustrated by the inability of her physicians to help her. She has episodes of severe pounding headache, with palpitations, profuse perspiration, and pallor, but by the time she gets to her doctor's office she checks out normal in every respect.
How should this patient be managed? |
- Start with 24-hour urinary determination of metanephrine of vanillylmandelic acid (VMA) - Follow with CT scan of adrenal gland - Surgery will eventually be done, with careful pharmacologic preparation with alpha-blockers |
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A 17-year old man is found to have a BP of 190/115. This is checked repeatedly in both arms, and it is always found to be elevated, but when checked in the legs it is found to be normal.
What is this? |
Coarctation of the aorta |
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A 17-year old man is found to have a BP of 190/115. This is checked repeatedly in both arms, and it is always found to be elevated, but when checked in the legs it is found to be normal.
How should this patient be managed? |
- Start with a CXR, looking for scalloping of the ribs - Next, non-invasive spiral CT enhanced with IV dye (CT angio) - Ultimately surgery |
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A 23-year old woman has had severe hypertension for 2 years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen.
What is this? |
Renovascular hypertension - caused by fibromuscular dysplasia |
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A 23-year old woman has had severe hypertension for 2 years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen.
How should this patient be managed? |
- Diagnosis: Duplex scanning of renal vessels, CT angio may also be helpful - Treatment: Since she is young, she must be treated; angiographic balloon dilation with stenting is the first choice, surgery is the alternative |
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A 72-year old man with multiple manifestations of arteriosclerotic occlusive disease has HTN of relatively recent onset and refractory to the usual medical therapy. He has a faint bruit over the upper abdomen.
What is this? |
Renovascular hypertension - caused by arteriosclerosis |
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A 72-year old man with multiple manifestations of arteriosclerotic occlusive disease has HTN of relatively recent onset and refractory to the usual medical therapy. He has a faint bruit over the upper abdomen.
How should this patient be managed? |
The decision is for more complex of whether to treat or not; this makes sense only if other manifestations of the arteriosclerosis are not going to kill him first |
