BMJ Case Histories Flashcards
A man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination.
Large bowel obstruction
A 27-year-old male presents with crampy abdominal pain of sudden onset, vomiting, and failure to pass any flatus or stool for 24 hours. The patient has no history of prior surgery. Physical examination reveals peritonitis, and abdominal x-rays demonstrate air-fluid levels.
Small bowel obstruction
A 43-year-old female with a prior history of open cholecystectomy presents with gradual onset of nausea, vomiting, obstipation, and abdominal distension. Physical examination does not demonstrate peritonitis. Abdominal x-rays demonstrate scattered air-fluid levels.
Small bowel obstruction
A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the RUQ that began after eating dinner and radiates through to her back. This pain gradually increased before becoming constant over the last few hours. She has had previous episodes of similar pain for which she has not sought medical advice. Her vital signs are normal. The pertinent findings on physical examination are tenderness to palpation in the right upper quadrant with no guarding or rebound.
Cholelithiasis
A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant RUQ pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.
Cholecystitis
A 51-year-old man with moderate obesity (BMI of 34 kg/m2) is seen in consultation for heartburn and regurgitation. He has a diagnosis of GORD and has been treated with proton-pump inhibitors. His heartburn is less severe with the medication, but he is still bothered by regurgitation. His physical examination is unremarkable. A barium oesophagram and upper endoscopy demonstrate a type I (sliding) hiatal hernia, with about one third of the upper stomach in the chest. The patient has free reflux to the level of the cervical oesophagus.
Hiatus hernia
A 48-year-old woman with a history of migraine headaches presents to the emergency department with altered mental status over the last several hours. She was found by her husband, earlier in the day, to be acutely disorientated and increasingly somnolent. On physical examination, she has scleral icterus, mild right upper quadrant tenderness, and asterixis. Preliminary laboratory studies are notable for a serum ALT of 6498 units/L, total bilirubin of 95.8 micromol/L (5.6 mg/dL), and INR of 6.8. Her husband reports that she has consistently been taking pain medications and started taking additional 500-mg paracetamol pills several days ago for lower back pain. Further history reveals a medication list with multiple paracetamol-containing preparations.
Acute liver failure
A 34-year-old man presents 2 weeks after returning from a month-long trip to India. He denies attending pre-travel vaccination clinic and did not take prophylaxis of any sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain, nausea with emesis, and dark urine. He admits to dietary indiscretion and consumed salad at a road-side vendor 3 weeks before onset of symptoms. On examination there is icterus. His ALT is 5660 units/L, and total bilirubin 153.9 micromols/L (9 mg/dL). Serum IgM anti-hepatitis A virus (HAV) antibodies are detected.
Hepatitis A
A 50-year-old man presents with 5 to 6 months of gradually worsening abdominal swelling, intermittent haematemesis, and dark stool. He denies chest pain or difficulty breathing. Past medical and family history are not contributory. Past surgical history is significant for back surgery requiring blood transfusion in 1980. Social history is significant for occasional alcohol use. BP is 110/80 mmHg. Physical examination is significant for spider angiomata on the upper chest, gynaecomastia, caput medusae, and a fluid wave of the abdomen. The rest of the examination is normal.
Hepatitis C
A 40-year-old asymptomatic man presents for a routine visit with elevated ALT level (55 international units [IU]/mL). His mother died of hepatocellular carcinoma and he has a middle-aged sister with “hepatitis B infection”. He has a normal physical examination and has no chronic stigmata of liver disease.
Hepatitis B
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated HTN and diabetes.
Ischaemic stroke
A 70-year-old man with a history of chronic HTN and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.
Haemorrhagic stroke
A 70-year-old man who smokes heavily presents with a 6-month history of intermittent abdominal pain and nausea. He has lost 10 kg of weight in the past 2 months, which he thinks is due to a decreased appetite, and he complains of pruritus. On physical examination there is icterus in the conjunctival sclerae and epigastric tenderness but no abdominal mass or lymphadenopathy. Blood tests demonstrate elevated bilirubin and alkaline phosphatase; the rest of the blood tests are within the normal range.
Pancreatic cancer
A 45-year-old woman presents to her physician with vague upper abdominal (epigastric) pain. After treatment with proton-pump inhibitors, analgesics, and antacids over a period of 3 months, which were ineffective, the patient also started to experience back pain. This prompted an initial upper gastrointestinal (UGI) endoscopy, which was normal. Nearly 4 months after initial presentation, an upper abdominal ultrasound reveals a pancreatic mass with liver metastases.
Pancreatic cancer
A 36-year-old fair-skinned woman presents with a dark, irregular, pigmented patch that she noted 4 months ago on the right posterior calf. It has gradually increased in size. She reports approximately 6 sunburns in the past and has been using tanning beds several times yearly for the past few years. Family history is positive for melanoma in her uncle. On physical examination, approximately 15 normal-appearing naevi, ranging in size from 3 mm to 5 mm, with symmetry, uniform brown coloration, and regular borders are noted elsewhere on the torso and extremities. The pigmented lesion on the right calf is asymmetrical along 2 axes, measures 1 cm x 0.8 cm, is deeply pigmented with several shades of brown, and has a jagged border. The popliteal nodes are not clinically palpable.
Melanoma
