DISKUSI PANEL

1. A 42-year-old overweight but otherwise healthy woman presents with sudden onset of right upper abdominal colicky pain 45 minutes after a meal of fried chicken. The pain is associated with nausea and vomiting, and any attempt to eat since has caused increased pain. •what is the most likely cause?

• What is next plan (imaging and lab)

• she is noted to have gallstones on ultrasonography. She is placed on a low-fat diet. After 3 months she is noted to have severe right upper quadrant pain, fever to 102°F, and nausea.

• what is the most likely diagnosis?

• What is next plan (lab and treatment)

2.A 37-year-old executive returns to your office for follow-up of recurrent upper abdominal pain. He initially presented 6 weeks ago, complaining of an increase in frequency and severity of burning epigastric pain, which he has experienced occasionally for more than 2 years. Now the pain occurs three or four times per week, usually when he has an empty stomach, and it often awakens him at night. The pain usually is relieved within minutes by food or over-the-counter antacids but then recurs within 2 to 3 hours.

• He admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine and eating a lot of take-out foods. His medical history and review of systems were otherwise unremarkable, and, other than the antacids, he takes no medications.

• His physical examination was normal, including stool guaiac that was negative for occult blood. You advised a change in diet and started him on an H2 blocker. His symptoms resolved completely with the diet changes and daily use of the medication..

• ➤ What is your diagnosis?

• What is next plan (imaging and lab)

• Results of laboratory tests performed at his first visit show no anemia, but his serum Helicobacter pylori antibody test was positive

• What is next plan

• 3. A 49-year-old woman presents to the emergency room complaining of a 4-week history of progressive abdominal swelling and discomfort.

• She has no other gastrointestinal symptoms, and she has a normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one of which was complicated by excessive blood loss, requiring a blood transfusion. She is happily married for 20 years, exercises, does not smoke, and drinks only occasionally.

• On pointed questioning, however, she does admit that she was “wild” in her youth, and she had snorted cocaine once or twice at parties many years ago. She does not use drugs now. She was HIV negative at the time of the birth of her last child.

• On examination, her temperature is 100.3°F, heart rate 88 bpm, and blood pressure 94/60 mm Hg. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. She has no peripheral edema.

• Laboratory studies are normal except for Na 129 mEq/L, albumin 2.8 mg/dL, total bilirubin 4 mg/dL, prothrombin time 15 seconds, hemoglobin 12 g/dL with mean cell volume (MCV) 102 fL, and platelet count 78,000/mm3.

• What is the most likely diagnosis?

• What is next plan

• 6. A 28-year-old man comes to the emergency room complaining of 2 days of abdominal pain and diarrhea. He describes his stools as frequent, with 10 to 12 per day, small volume, sometimes with visible blood and mucus, and preceded by a sudden urge to defecate. The abdominal pain is crampy, diffuse, and moderately severe, and it is not relieved with defecation. In the past 6 to 8 months, he has experienced similar episodes of abdominal pain and loose mucoid stools, but the episodes were milder and resolved within 24 to 48 hours. He has no other medical history and takes no medications. He had contact with anyone with similar symptoms. He works as an accountant and does not smoke or drink alcohol. No member of his family has gastrointestinal (GI) problems.

• On examination, his temperature is 99°F, heart rate 98 bpm, and blood pressure 118/74 mm Hg. He appears uncomfortable, is diaphoretic, and is lying still on the stretcher. His sclerae are anicteric, and his oral mucosa is pink and clear without ulceration. His chest is clear, and his heart rhythm is regular, without murmurs. His abdomen is soft and mildly distended, with hypoactive bowel sounds and minimal diffuse tenderness but no guarding or rebound tenderness.

• ➤ What is the most likely diagnosis?

• What is next plan

• Laboratory studies are significant for a white blood cell (WBC) count of 15,800/mm3 with 82% polymorphonuclear leukocytes, hemoglobin 10.3 g/dL, and platelet count 754,000/mm3. The HIV (human immunodeficiency virus) assay is negative. Renal function and liver function tests are normal. A plain film radiograph of the abdomen shows a mildly dilated air-filled colon with a 4.5-cm diameter and no pneumoperitoneum or air/fluid levels.

• What is the most likely diagnosis?

• What is next plan

• 7. A 35-year-old woman has chronic crampy abdominal pain and intermittent constipation and diarrhea, but no weight loss or gastrointestinal bleeding. Her abdominal pain is usually relieved with defection.

• What is next plan?

• Colonoscopy and upper endoscopy with biopsies are normal, and stool cultures are negative.

• What is the most likely diagnosis?