75-year-old with abdominal aorta aneurysm

A 75-year-old male undergoes an abdominal CT looking for liver metastases from a known colonic adenoma. On the CT a 4.9 cm abdominal aortic aneurysm (AAA). Which of the following risk factors is NOT a contributor to this pt's AAA?


a) His age.
b) Hypercholesterolemia.
c) Diabetes.
d) Smoking.
e) Hypertension.


Answer:

65-year-old Male With Testicular Hernia

You have been asked to perform a preoperative consultation on a 65-year-old male who will be undergoing a testicular hernia repair. Of the following findings, which is of most concern in predicting a cardiac complication in this patient undergoing noncardiac surgery?

a) Age over 60
b) History of myocardial infarction 3.5 years ago
c) Harsh systolic crescendo-decrescendo murmur radiating to the carotids
d) ECG and subsequent telemetry showing up to five PVCs per minute
e) Serum creatinine 2.0 mg/dL

Answer:

34 year-old Man With Intermittent Melena

A 34-year-old man presents to the emergency department(ED) with intermittent melena of 3 days’ duration. He is mildly fatigued but hemodynamically stable and denies any hematemesis or coffee ground emesis. His serum hemoglobin level is 8.2 g/dL. Intravenous (IV) fluids are started. Physical examination is essentially unremarkable. What is the next best step in this patient’s evaluation?

A. Check serum Helicobacter pylori antibody levels
B. Perform a colonoscopy
C. Perform an esophagogastroduodenoscopy(EGD)
D. Start a histamine2 receptor antagonist (H2 blocker)
E. Transfuse 2 U of packed red blood cells

Answer: 

The Case of the Sickly Scribbler With an Agonizing Belly Ache

The patient was a 59-year-old white male author who complained of severe abdominal pain.

Personal History

The patient was the eldest of 10 children. Two siblings died of typhoid -- one from peritonitis secondary to a perforated intestinal ulcer that had been caused by the disease. His mother died of abdominal cancer at age 44 and his father died at age 82. As an adult, the patient smoked and drank copious amounts of white wine -- often becoming inebriated. He led an irregular life, frequently moving, sometimes eating poorly, and, although he had multiple medical problems, he often failed to comply with medical advice. He had 2 children, a son and a daughter who required frequent hospitalization for attacks of schizophrenia.

Medical History

Throughout adulthood, the patient experienced a number of severe medical conditions. At age 27, he was hospitalized with what was thought to be rheumatic fever, which was followed by attacks of polyarthritis over the course of his life. The patient also suffered from attacks of iritis and glaucoma, which were treated with medications and applications of leeches. He also underwent multiple eye operations. Despite these efforts, his vision gradually deteriorated. In later life, he became blind in his right eye, with limited vision in his left eye. Eventually he could only write using crayons to form large letters, depending on friends to type his manuscripts. Additional health problems included severe dental caries, sciatica, and tonsillitis. Beginning in his twenties, the patient had several attacks of upper abdominal pain, sometimes lasting for a week or more. It was after a final attack that the patient died. Until this last event, his physicians never obtained abdominal x-rays, nor had they succeeded in establishing a definitive diagnosis for the abdominal condition.

Final Illness

His final illness began with "stomach cramps" after an evening meal washed down with copious amounts of white wine. The abdominal pain became so severe that at 4:00 AM the patient called a local physician who administered morphine. Later that day, a surgeon visited the patient and advised hospitalization. The next morning, abdominal x-rays were obtained, and approximately 30 hours after the initial onset of pain, the patient underwent an abdominal operation. For the first several postoperative hours, the patient seemed to be doing well, but he soon weakened. The dLay following surgery, he developed gastrointestinal bleeding and received 2 transfusions. Unfortunately, he soon lapsed into a coma and died on the second postoperative day.^[2] An autopsy was performed.

What is your diagnosis?

1. Intestinal obstruction
2. Ruptured peptic ulcer
3. Ruptured aortic aneurysm
4. Mallory-Weiss syndrome 

77 year-old Lady With Left Iliac Fossa Pain

Madam LGY,77 years old presented with left iliac fossa pain for the past 3 weeks radiating to the whole abdomen and constant. The pain has been there for the past 5 years but has increased in intensity in the past 3 weeks. She has tenesmus also for 3 weeks. She has altered bowel habits for the past 5 years where she passes 4-5times each day. There was no blood in the stools.She has associated dizziness and tiredness. She has loss of appetite and loss of weight and sleep is also disturbed.Patient was discharged while awaiting appointment for MRI.

On examination, the patient was comfortable and not in obvious pain.Her pulse rate was 52bpm and regular. There was pallor under her conjunctiva. On examination,her abdomen was distended but umbilicus was inverted. It was soft on palpation with slight guarding and tenderness at the left iliac fossa.

INVESTIGATION
Ultrasound:Bowel mass noted.
Colonoscope:Mass found at sigmoid colon,scope was unable to pass through.

FBC

RBC: 3.0X10¹² /L

Hb    :11g/dL

1. What are your differential diagnosis and provisional diagnosis?

2. How do we manage the patient ?

40 year-old Man With Difficulty In Swallowing

Mr. J, a 40 years old Malay gentle man was referred from JB hospital for suspected Achalasia Cardia. He was previously well until 9 months ago, he started to experience constant difficulty in swallowing his food particularly solid food. This was also associated with increased burping and regurgitation of food particles after eating. There was  significant loss of weight as a result of poor feeding. Mr. J however, denied  history  of loss in appetite, pain while swallowing, vomiting of blood and passing out black colored stools. Past medical history and family history of malignancy were not significant.

Q1 What are the differential diagnosis do you have in mind?

 

Q2: What are the investigations to confirm your diagnosis?

72 year-old Lady With Lower Abdominal Pain And Rectal Bleeding

A 72 year old lady presented with a three month history of colicky lower abdominal pain and rectal bleeding. Rectal and sigmoidoscopic examinations were unremarkable. A barium enema was requested. This image is from a barium enema series. 

How do you describe the radiological finding? What is the diagnosis?