BMJ Cases Flashcards
A 52-year-old man presents with a 6-month history of heartburn and atypical chest pain, both unrelated to food. He also described ‘gurgling’ sounds in his chest. A month before presentation he developed intermittent dysphagia to both solids and liquids, regurgitation, and weight loss of 3 kg.
What is the diagnosis
Achalasia
more; Patient may need to adopt certain positions or manoeuvres to ease swallowing.
A 65-year-old woman presents to the emergency department with a 2-day history of progressive RUQ pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have started to become loose but with no diarrhoea, bright red blood, or black tarry stools. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs (NSAIDs) or drink alcohol.
On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Faecal occult blood test is negative. Laboratory results show a WBC of 18.0 x 10^9/L (18,000/microlitre) (reference range 4.8-10.8 x 10^9/L or 4800-10,800/microlitre) with 17% (reference range 0% to 4%) bands and PMNs of 82% (reference range 35% to 70%). AST is 207 units/L (reference range 8-34 units/L), ALT is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 107.7 micromol/L (6.3 mg/dL) (reference range 3.4-22.2 micromol/L or 0.2-1.3 mg/dL), and amylase is 82 units/L (53-123 units/L).
Acute cholangitis
A 28-year-old woman presents with a history of severe pain on defecation for the last 3 months. She has noticed a small amount of blood on the stool. The pain is severe and she is worried about the pain she will experience with the next bowel action.
anal fissure
A 50-year-old man presents to his general practitioner with complaints of fatigue for 2 months. The patient also notes distension of his abdomen and shortness of breath beginning 2 weeks ago. His wife reports that the patient has been having episodes of confusion lately. The patient has a significant medical history of chronic heavy alcohol consumption of about half a pint of vodka daily for around 20 years. On physical exam the patient is noted to have scleral icterus, tremors of both hands, and spider angiomata on the chest. There is abdominal distension with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low haemoglobin, low platelets, low sodium, AST elevation > ALT elevation, and high PT and INR. Ultrasound of the abdomen shows liver hyperechogenicity, portal hypertension, splenomegaly, and ascites.
alcoholic liver
A 45-year-old woman presents with insidious onset of fatigue, malaise, lethargy, anorexia, nausea, abdominal discomfort, mild pruritus, and arthralgia involving the small joints. Her past medical history includes coeliac disease. Physical examination reveals hepatomegaly and spider angiomata.
autoimmune hepatitis
A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C; 100.5°F), pain on palpation at right lower quadrant (McBurney’s sign), and leukocytosis (12 x 10^9/L or 12,000/microlitre) with 85% neutrophils.
acute appendicitis
A 55-year-old obese man presents with frequent heartburn. He describes a post-prandial, retrosternal burning sensation following fatty and spicy meals. This symptom also frequently wakes him from sleep, with occasional coughing and a sour taste in his throat. He has tried many OTC antacids, which only relieve symptoms in the short term. He has suffered from this symptom for over 10 years. He denies dysphagia, odynophagia, or weight loss, but reports frequent hoarseness in the mornings. His past medical history is significant only for HTN. His family history is unremarkable. He did smoke cigarettes, but stopped 5 years ago.
barretts oesophagus
A 58-year-old man with pancreatic adenocarcinoma, who had a plastic stent placed in his common bile duct 6 weeks ago to relieve obstructive jaundice, presents to the emergency department after 1 week of progressive nausea and occasional vomiting after eating. He has generalised abdominal pain that is worse in the RUQ. He has experienced subjective fever/chills and states that his bowel movements are pale. Laboratory results show a WBC of 14.0 x 10^9/L (14,000/microlitre) (reference range 4.8-10.8 x 10^9/L or 4800-10,800/microlitre) with 8% (reference range 0% to 4%) bands and PMNs of 77% (reference range 35% to 70%). AST is 214 units/L (reference range 8-34 units/L), ALT is 181 units/L (reference range 7-35 units/L), alkaline phosphatase is 543 units/L (reference range 25-100 units/L), total bilirubin is 183.0 micromol/L (10.7 mg/dL) (reference range 3.4-22.2 micromol/L or 0.2-1.3 mg/dL), and amylase is 110 units/L (reference range 53-123 units/L).
Acute cholangitis
A 38-year-old man presents to the emergency department for severe alcohol abuse with nausea and vomiting. He has a significant medical history of chronic heavy alcohol consumption of half a pint of vodka daily for about 5 years until 1 year ago; since then he has had severe intermittent binge alcohol intake. He reports no other significant medical problems. The patient is confused and slightly obtunded, and hepatomegaly is discovered on physical exam. His BMI is 22. Pertinent positive laboratory values show low haemoglobin, AST elevation > ALT elevation, normal PT and INR, and very high serum alcohol level. Ultrasound of the abdomen shows fatty infiltration in the liver.
alcoholic liver
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 56-year-old man with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical examination reveals telangiectasias, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (AST: 90 U/L, ALT: 87 U/L), and the patient is positive for anti-hepatitis C antibody.
cirrhosis
A 12-year-old girl presents with sudden-onset severe generalised abdominal pain associated with nausea, vomiting, and diarrhoea. On examination she appears unwell and has a temperature of 40°C (104°F). Her abdomen is tense with generalised tenderness and guarding. No bowel sounds are present.
acute appendicitis
A 51-year-old man with moderate obesity (body mass index of 34 kg/m²) is seen in consultation for heartburn and regurgitation. He has a diagnosis of gastro-oesophageal reflux disease 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) hiatus 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 46-year-old woman presents with fatigue and is found to have iron deficiency with anaemia. She has experienced intermittent episodes of mild diarrhoea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms such as diarrhoea, bloating, or abdominal pain. Examination reveals two oral aphthous ulcers and pallor. Abdominal examination is normal and results of faecal testing for occult blood are negative.
coeliac disease
A 60-year-old woman with a past medical history of obesity, diabetes, and dyslipidaemia is noted to have abnormal liver enzymes with elevated aminotransferases (ALT: 68 U/L, AST: 82 U/L), and normal alkaline phosphatase and bilirubin. She denies significant alcohol consumption, and tests for viral hepatitis and autoimmune markers are negative. An abdominal ultrasound reveals evidence of fatty infiltration of the liver and slight enlargement of the spleen.
cirrhosis
A 68-year-old retired labourer presents to his primary medical doctor with a 3-week history of a dull dragging discomfort in his right groin toward the end of the day. The discomfort is associated with a lump while standing but disappears when lying supine. He denies any other significant past medical or surgical history. On physical examination, a bulge is present when standing that disappears when supine.
inguinal hernia
A 42-year-old man presents to his primary care physician complaining of a 3-month history of lower intestinal bleeding. He describes the bleeding as painless, bright blood appearing on the tissue following a bowel movement.
He has had 2 episodes recently where blood was visible in the toilet bowl following defecation. He denies any abdominal pain and any family history of GI malignancy. Physical examination reveals a healthy man with the only finding being bright blood on the examining finger following a digital rectal examination.
haemorrhoids
A 9-year-old boy presents with vomiting for 5 days. His sister, who has coeliac disease, has had similar symptoms. His growth has been normal and he has not experienced any other possible symptoms of coeliac disease, except for intermittent constipation. Immunoglobulin A-tissue transglutaminase titre is 5 times the upper limit of normal.
coeliac disease
A 25-year-old white man presents to his general practitioner with cramping abdominal pain for 2 days. He reports having loose stools and losing 6.8 kg over a 3-month duration. He also reports increased fatigue. On physical examination, his temperature is 37.6°C (99.6°F). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the right lower quadrant, without guarding or rigidity. Rectal examination is normal and the stool is guaiac positive. The rest of the examination is unremarkable.
chrons
A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4 to 6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. The patient has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss.
Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m (5 feet 4 inches), weight 77.1 kg, and BP 140/88 mmHg. The remainder of the examination is unremarkable.
GORD
A 28-year-old woman presents complaining of rectal pain of 3 days’ duration. She states that on the day before the onset of symptoms she had been moving boxes at her home. She describes the pain as sharp and present constantly, but worse with bowel movements or sitting. She denies any fevers or chills or perianal discharge. Physical examination reveals a 2-cm, painful, bluish lesion adjacent to the anal canal.
haemorrhoids
A 57-year-old female with history of hypertension and hypercholesterolaemia presents to the emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting.
Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for GI disorders.
diverticular disease
A 42-year-old man presents with a 48-hour history of bloody diarrhoea. He has 6 to 8 bowel movments per day, and associated nausea, lethargy, and generalised abdominal discomfort. There is no recent travel history. He lives with his wife and 2 children, who are all well. They had a meal in a restaurant 5 days ago, when he ate a beef burger and French fries.
A friend who was with them ate the same meal and has developed similar symptoms. Exam shows a low-grade fever (38°C [100.5°F]) but is otherwise unremarkable. Full blood count reveals an elevated white blood cell count (15,000/mm³). Stool culture results are available 3 days later and are positive for Escherichia coli , and serotyping confirms the presence of E coli O157:H7.
gastroenteritis; foodborne e.coli infection
A 20-year-old man reports chronic offensive discharge of pus and blood from his natal cleft. He relates that several months previously he had a ‘boil’ in the same region, which was painful and then burst spontaneously. On examination, the patient has dense body hair. There are several sinus tracts in the midline or just lateral to the natal cleft, from which offensive-smelling discharge can be expressed.
pilonidal disease (sinus?)
