A 50-year-old man comes to the emergency room with a history of vomiting for three days' duration. His past history reveals that for approximately 20 years, he has been getting epigastric pain, lasting for two to three weeks. He remembers getting relief from pain by taking milk and antacids. Physical examination showed a fullness in the epigastric area with visible peristalsis, absence of tenderness and normal active bowel sounds.
Which one of the following is the most likely diagnosis?
Correct Answer A:
Intrinsic or extrinsic obstruction of the pyloric channel or duodenum is the usual pathophysiology of gastric outlet obstruction (GOO). Nausea and vomiting are the cardinal symptoms of GOO. Vomiting usually is described as non-bilious, and it characteristically contains undigested food particles. In the early stages of obstruction, vomiting may be intermittent and usually occurs within 1 hour of a meal.
Early satiety and epigastric fullness are common. Weight loss is frequent when the condition approaches chronicity and is most significant in patients with malignant disease. Abdominal pain is not frequent. Physical examination often demonstrates the presence of chronic dehydration and malnutrition. A dilated stomach may be appreciated as a tympanitic mass in the epigastric area and/or left upper quadrant.
Plain abdominal radiographs, contrast upper GI studies (Gastrografin or barium), and CT scans with oral contrast are helpful. Plain radiographs, including the obstruction series (ie, supine abdomen, upright abdomen, chest posteroanterior), can demonstrate the presence of gastric dilatation and may be helpful in distinguishing the differential diagnosis.
Upper endoscopy can help visualize the gastric outlet and may provide a tissue diagnosis when the obstruction is intraluminal. Treatment is surgical.
A 38-year-old nurse presents with a 6-week history of nervousness, fatigue, palpitations, and reduced appetite. The physical examination is notable only for lid lag and a slight diffuse enlargement of her thyroid gland. A laboratory evaluation is notable for:
Correct Answer D: A normal or elevated serum thyrotropin level associated with an elevated free serum thyroxine level is most consistent with a thyrotropin-secreting pituitary adenoma or a thyroid hormone resistance syndrome. All of the other conditions listed are associated with an elevated free thyroxine level, but would result in a suppressed serum thyrotropin level.
A 60-year-old man presents with a small lesion on his nose. On examination of the lesion you note the following: the lesion is 3 mm in diameter, slightly elevated with a waxy appearance, and has a slight vascular pattern on top.
This lesion is most characteristic of which one of the following?
Basal cell carcinoma is a superficial slowly growing papule or nodule that derives from epidermal basal cells.
Most commonly, the carcinoma begins as a shiny papule, enlarges slowly, and after a few months or years, shows a shiny, pearly border with prominent engorged vessels (telangiectases) on the surface and a central dell or ulcer.
Metastasis is rare, but local growth can be highly destructive. Diagnosis is by biopsy. Treatment depends on the tumor's characteristics and may involve curettage and electrodesiccation, surgical excision, cryosurgery, or, occasionally, radiation therapy.
A 30-year-old man has a history of recurrent pneumonias and chronic cough dating from early childhood. The cough, which is worse in the morning and on lying down, is productive of foul-smelling purulent sputum which is occasionally bloody-tinged. The patient is chronically ill and has clubbed fingers. Rales are heard over the posterior lung bases.
Correct Answer E:
Bronchiectasis is dilation and destruction of larger bronchi caused by chronic infection and inflammation. Common causes are cystic fibrosis, immune defects, and infections, though some cases appear to be idiopathic. Symptoms are chronic cough and purulent sputum expectoration; some patients may also have fever and dyspnea.
Diagnosis is based on history and imaging, usually involving high-resolution CT, though standard chest x-rays may be diagnostic. Treatment and prevention of acute exacerbations are with antibiotics, drainage of secretions, and management of complications, such as superinfection and hemoptysis. Treatment of underlying causes is important whenever possible.
You see a 55-year-old female for the first time. She has a 2-year history of chronic daily cough; thick, malodorous sputum; and occasional hemoptysis. She has been treated with antibiotics for recurrent respiratory infections, but is frustrated with her continued symptoms. She has never smoked. Her FEV1:FVC ratio is 60% and a CT scan shows bronchial wall thickening and luminal dilation.
The most likely diagnosis is:
Correct Answer B:
Bronchiectasis is an illness of the bronchi and bronchioles involving obstructive and infectious processes that injure airways and cause luminal dilation. In addition to daily viscid, often purulent sputum production with occasional hemoptysis, wheezing and dyspnea occur in 75% of patients. Emphysema and chronic 1 bronchitis, forms of COPD, also cause a decreased FEV :FVC ratio, but the baseline sputum is generally mucoid and luminal dilatation of bronchi is not characteristically present. Bronchiolitis is usually secondary to respiratory syncytial virus infection in young children. Asthma is not characterized by the sputum and CT findings seen in this patient.
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