Transcript What is the best treatment?

OSCE
Raika Jamali M.D.
Gastroenterologist and hepatologist
Sina hospital
Tehran University of Medical Sciences
Case 56


A middle age woman with mild
abdominal pain that tolerate food
intake.
You see the CT scan of patient in next
slides.
Physical examination:
Conscious, cooperative
Vital signs are stable.
No Icteric sclera,
She was not pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Epigastric tenderness,
No Morphy sign,
Liver span=12 cm,
No shifting dullness,
Lab findings
Hb = 13.4 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 9100 , poly = 68% lymph = 27%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 4.4 g/dl / total protein = 5.7g/dl
BUN, Creatinine= normal
24 hour urinary protein= normal
AST = 79 U/L
ALT = 62 U/L
T= 1.2
Bilirubin
mg/dl
D=0.8
Alkaline phosphatase = 769 U/L
Viral markers = negative
Amylase = 100
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Acute mild pancreatitis
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Focal nodular hyperplasia
What is the best treatment?





A) Prompt surgical consult for
resection
B) Intraveous antibiotic plus
appropriate hydration
C) CT guided percutaneous aspiration
D) Angiographic chemoembolization
E) Follow up visits
Case 57


A middle age man with RUQ pain and
vomiting.
You see the CT scan of patient in 48
hours after the onset of pain.
Physical examination:
Conscious, cooperative
BP  120
80
PR  95
min
Icteric sclera,
He was pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Epigastric tenderness,
No Morphy sign,
Liver span=12 cm,
Shifting dullness,
T (oral) = 37.5°c
Lab findings
Hb = 9.4 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 12100 , poly = 88% lymph = 12%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 4.4 g/dl / total protein = 5.7g/dl
BUN, Creatinine= normal
24 hour urinary protein= normal
AST = 119 U/L
ALT = 122 U/L
T= 3.2
Bilirubin
mg/dl
D=1.8
Alkaline phosphatase = 769 U/L
Viral markers = negative
Amylase = 1000
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Acute mild pancreatitis
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Intra peritoneal metastasis
What is the best treatment?





A) Prompt surgical consult for
resection
B) Intraveous antibiotic plus
appropriate hydration
C) A & B
D) CT guided percutaneous aspiration
E) Angiographic chemoembolization
Case 58


A middle age woman with chronic
abdominal pain.
You see the CT scan of patient in next
slides.
Physical examination:
Conscious, cooperative
Vital signs are stable.
No Icteric sclera,
She was not pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Epigastric tenderness,
No Morphy sign,
Liver span=12 cm,
No shifting dullness,
Lab findings
Hb = 13.4 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 9100 , poly = 68% lymph = 27%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 4.4 g/dl / total protein = 5.7g/dl
BUN, Creatinine= normal
24 hour urinary protein= normal
AST = 49 U/L
ALT = 42 U/L
T= 1.2
Bilirubin
mg/dl
D=0.8
Alkaline phosphatase = 769 U/L
Tumor markers = negative
Amylase = 100
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Acute mild pancreatitis
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Intra peritoneal metastasis
What is the best treatment?





A) Prompt surgical consult for
resection
B) Intraveous antibiotic plus
appropriate hydration
C) ERCP for drainage and pancreatic
stent placement
D) CT guided percutaneous aspiration
E) Angiographic chemoembolization
Case 60


A middle age woman with chronic
abdominal pain and weight loss.
You see the CT scan of patient in next
slides.
Physical examination:
Conscious, cooperative
Vital signs are stable.
No Icteric sclera,
She was not pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Epigastric tenderness,
No Morphy sign,
Liver span=12 cm,
No shifting dullness,
Lab findings
Hb = 13.4 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 9100 , poly = 68% lymph = 27%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 4.4 g/dl / total protein = 5.7g/dl
BUN, Creatinine= normal
24 hour urinary protein= normal
AST = 49 U/L
ALT = 42 U/L
T= 1.2
Bilirubin
mg/dl
D=0.8
Alkaline phosphatase = 769 U/L
CEA & CA 19-9 > 3 Upper limit normal range
Amylase = 100
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Acute mild pancreatitis
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Pancreatic cyst adenocarcinoma
What is the best treatment?





A) Prompt surgical consult for
resection
B) Intraveous antibiotic plus
appropriate hydration
C) ERCP for drainage and pancreatic
stent placement
D) CT guided percutaneous aspiration
E) Angiographic chemoembolization
Case 61


A middle age woman with epigastric
pain.
You see the CT scan of patient in next
slides.
Physical examination:
Conscious, cooperative
BP  120
80
PR  95
min
Icteric sclera,
She was not pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Epigastric tenderness,
No Morphy sign,
Liver span=12 cm,
Shifting dullness,
T (oral) = 39.5°c
Lab findings
Hb = 11.4 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 12100 , poly = 88% lymph = 12%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 3.4 g/dl / total protein = 5.7g/dl
BUN, Creatinine= normal
24 hour urinary protein= normal
AST = 119 U/L
ALT = 122 U/L
T= 3.2
Bilirubin
mg/dl
D=1.8
Alkaline phosphatase = 969 U/L
Tumor markers = negative
Amylase = 1000
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Acute mild pancreatitis
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Pancreatic cyst adenocarcinoma
What is the best treatment?






A) Prompt surgical consult for
resection
B) Intraveous antibiotic plus
appropriate hydration
C) A & B
D) ERCP for drainage and pancreatic
stent placement
E) CT guided percutaneous aspiration
F) Angiographic chemoembolization
Case 62


A middle age woman with epigastric
pain and shock.
You see the CT scan of patient in next
slides.
Physical examination:
Conscious, cooperative
BP  80
pulse
PR  115
min
Icteric sclera,
She was pale,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Epigastric tenderness,
No Morphy sign,
Liver span=12 cm,
Shifting dullness,
T (oral) = 37.5°c
Lab findings
Hb = 6.4 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 12100 , poly = 88% lymph = 12%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 3.4 g/dl / total protein = 5.7g/dl
AST = 119 U/L
ALT = 122 U/L
T= 3.2
Bilirubin
mg/dl
D=1.8
Alkaline phosphatase = 969 U/L
Tumor markers = negative
Amylase = 1000
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Hemorrhagic pancreatic pseudocyst
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Pancreatic cyst adenocarcinoma
What is the best treatment?






A) Prompt surgical consult for
hemostasis
B) Blood transfusion plus appropriate
hydration
C) A & B
D) ERCP for drainage and pancreatic
stent placement
E) CT guided percutaneous aspiration
F) Angiographic chemoembolization
Case 63



A middle age man with abdominal
distention.
He had hepatosplenomegaly without
shifting dullness in physical exam.
You see the CT scan of patient in next
slides.
Physical examination:
Conscious, cooperative
Blood pressure: 180/ 110 mm Hg.
No Icteric sclera,
She was not pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Hepatosplenomegaly was detected,
No Morphy sign,
No sign of portal hypertension,
No shifting dullness,
Lab findings
Hb = 14 gr/dl, RBC = 5.1x10 6 , MCV=102,
MCH & MCHC = normal
PLT = 217000
WBC = 6100 , poly = 45% lymph = 55%
ESR = 22 , PT = 12.5 sec. INR = 1.1,
Albumin = 3.4 g/dl / total protein = 5.7g/dl
Creatinine = 2.5 mg/dl U/A = normal
AST = 119 U/L
ALT = 122 U/L
T= 3.2
Bilirubin
mg/dl
D=1.8
Alkaline phosphatase = 969 U/L
Tumor markers = negative
Na = 145 mEq/l K= 4.5 mEq/L
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Primary amyloidosis
Primary liver lymphoma
Liver metastasis
AD Polycystic kidney disease
Intra peritoneal carcinomatosis
Storage diseases
What is the best treatment?





A) Prompt surgical consult for
resection
B) Diagnostic laparoscopy
C) Control of hypertension and low
salt diet
D) liver and kidney transplantation
E) CT guided percutaneous aspiration
Case 64



An old man with lower abdominal
pain.
He had tenderness in LLQ.
You see the abdominal sonography
and CT scan of patient in the next
slides.
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Hemorrhagic pancreatic pseudocyst
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Pancreatic cyst adenocarcinoma
What is the best treatment?






A) Prompt surgical consult for
hemostasis
B) Blood transfusion plus appropriate
hydration
C) A & B
D) ERCP for drainage and pancreatic
stent placement
E) CT guided percutaneous aspiration
F) Angiographic chemoembolization
Case 65



A young man with epigastric pain.
She had hepatomegaly in physical
exam.
You see the CT scan of the patient in
next slide.
What is your diagnosis?
A)
B)
C)
D)
E)
F)
Pancreatic abscess
Hemorrhagic pancreatic pseudocyst
Pancreatic pseudocyst
Chronic pancreatitis
Necrotizing pancreatitis
Pancreatic cyst adenocarcinoma
What is the best treatment?






A) Prompt surgical consult for
hemostasis
B) Blood transfusion plus appropriate
hydration
C) A & B
D) ERCP for drainage and pancreatic
stent placement
E) CT guided percutaneous aspiration
F) Angiographic chemoembolization