case 8 منقول

موضوع: case 8 منقول الجمعة مارس 27, 2009 3:57 pm

A 64-year-old black woman is transferred directly from her primary care provider's (PCP) office to the emergency department (ED) because of her presentation of symptomatic anemia and several episodes of painless rectal bleeding.

During an initial assessment, the patient states that she "can hardly walk", and that she has dyspnea on exertion, chest pain, and "ringing in the ears".

She denies any previous history of gastrointestinal ulcers, liver disease, or bleeding disorders. Although no medication list is available on admission, she denies anticoagulant, aspirin (ASA), and nonsteroidal anti-inflammatory drug (NSAID) intake.

The patient also denies smoking, as well as alcohol and recreational drug use.

Her past medical history is remarkable for type II diabetes mellitus, colonic diverticulosis, chronic anemia, recurrent rectal bleeding, colonic polyps, coronary artery disease, hypertension, and end-stage kidney disease requiring hemodialysis.

When further queried regarding her past medical history, the patient admits to 2 previous hospital admissions for similar problems. She has received multiple blood transfusions, 2 colonoscopies, 2 upper gastrointestinal endoscopies, and a negative gastrointestinal bleeding scan.

On physical examination, her oral temperature is 98.6°F (37.0°C). Her pulse is regular, with a rate of 107 bpm. Her blood pressure is 144/70 mm Hg. Significant orthostatic changes are noted in the patient's pulse and blood pressure. Her respiratory rate is 24 breaths/min, with mildly increased work of breathing. She appears pale and cachectic, and her oral mucosa is observed to be dry.

The examination of the head and neck is normal, with no palpable masses or cervical lymphadenopathy. Her lungs are clear to auscultation, but she is tachypneic. Her heart evaluation demonstrates normal S1 and S2 heart sounds and a mild systolic murmur. Her abdomen is protuberant, obese, and soft. There is no tenderness to deep palpation, and no rebound or guarding is noted. Normal bowel sounds are auscultated.

The peripheral arterial pulses in the upper and lower extremities are faintly palpable. A venous shunt is palpated in the right upper extremity, with a normal thrill. The rectal examination reveals dark red blood in the rectum.

The rest of the examination is unremarkable, except for external hemorrhoids without any visible active bleeding.

The initial workup includes a normal chest radiograph and an electrocardiogram (ECG) showing sinus tachycardia. The remaining findings are nonspecific.

The patient's cardiac enzyme examination is within normal limits. Other laboratory examinations, however, reveal a hemoglobin of 3.6 g/dL (36 g/L), a hematocrit of 12.2% (0.122), a platelet count of 295 × 103/µL (295 × 109/L), a prothrombin time of 12.3 seconds, and a partial thromboplastin time of 22.6 seconds.

The test of the liver enzymes is within normal limits.

The patient is treated in the ED with intravenous fluids, packed red blood cells, and intravenous proton pump inhibitors (PPIs). A gastroenterologist is urgently consulted. An emergent upper endoscopy is performed, which does not reveal the source of bleeding. The patient is admitted to the hospital and subsequently undergoes an autologous red blood cell scan, which is also unremarkable.

An anterograde single-balloon enteroscopy with fluoroscopy is performed. This shows an area of active bleeding approximately 160 cm from the incisors. After flushing the area with tap water, a visible vessel is seen, with normal surrounding mucosa and no evidence of ulceration

What is the diagnosis? Hint: Note the history of intermittent large-volume hematochezia and the extensive inconclusive workups for past episodes of bleeding.
	1-Esophageal varices
	2-Gastritis
	3-Dieulafoy lesion
	4-Diverticular bleed يللا يا جماعة .... ايه رأيكوا

موضوع: رد: case 8 منقول الجمعة مارس 27, 2009 5:35 pm

شكرا علي الحاله دكتور تاجو معلش قمنا ببعض التعديلات علي الخط والألوان بعد إذن حضرتك عشان تكون مريحه للعين القارئ نظرا لطول الموضوع

موضوع: رد: case 8 منقول السبت مارس 28, 2009 5:48 am

thanks Tagho for the problem
i think it is a diverticular bleeding
is that right?

موضوع: رد: case 8 منقول السبت مارس 28, 2009 12:35 pm

ايه سبب اختيارك؟
رجاء الاجابة مع ذكر حجج الاختيار

موضوع: رد: case 8 منقول السبت مارس 28, 2009 4:43 pm

الاجابة خلال ثلاثة ايام
يللا شددوا حيلكم

موضوع: رد: case 8 منقول الأحد مارس 29, 2009 7:28 pm

شكرا يا د.تاجو على الحالة الجميلة.

بصراحة الحالة صعبة، لأني لم أقابلها أوأقرأها من قبل.

والبحث عنها صعب للغاية!

لذلك أنا لن أستطيع الإجابة وسأنتظر إجابتك التي أتمنى أن تكون وافية

موضوع: رد: case 8 منقول الأحد مارس 29, 2009 7:32 pm

أقصد أرجو أن تكون وافية Smile

موضوع: رد: case 8 منقول الأحد مارس 29, 2009 10:17 pm

انا مش هاقول اذا كلنت صعبة او سهلة بس خلينا نقترح اختيار و نحاول نثبته
يللا يا جماعة و شددوا حيلكوا
لا يسمح بالانتظار لابد من المحاولة

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