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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. Vital signs are stable. No Icteric sclera,

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  1. OSCE Raika Jamali M.D. Gastroenterologist and hepatologist Sina hospital Tehran University of Medical Sciences

  2. Case 56 • A middle age woman with mild abdominal pain that tolerate food intake. • You see the CT scan of patient in next slides.

  3. 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, Physical examination: Conscious, cooperative

  4. 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

  5. AST = 79 U/L ALT = 62 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Amylase = 100 T= 1.2 Bilirubin mg/dl D=0.8

  6. What is your diagnosis? • Pancreatic abscess • Acute mild pancreatitis • Pancreatic pseudocyst • Chronic pancreatitis • Necrotizing pancreatitis • Focal nodular hyperplasia

  7. 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

  8. 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.

  9. T (oral) = 37.5°c 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, Physical examination: Conscious, cooperative

  10. 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

  11. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Amylase = 1000 T= 3.2 Bilirubin mg/dl D=1.8

  12. What is your diagnosis? • Pancreatic abscess • Acute mild pancreatitis • Pancreatic pseudocyst • Chronic pancreatitis • Necrotizing pancreatitis • Intra peritoneal metastasis

  13. 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

  14. Case 58 • A middle age woman with chronic abdominal pain. • You see the CT scan of patient in next slides.

  15. 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, Physical examination: Conscious, cooperative

  16. 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

  17. AST = 49 U/L ALT = 42 U/L Alkaline phosphatase = 769 U/L Tumor markers = negative Amylase = 100 T= 1.2 Bilirubin mg/dl D=0.8

  18. What is your diagnosis? • Pancreatic abscess • Acute mild pancreatitis • Pancreatic pseudocyst • Chronic pancreatitis • Necrotizing pancreatitis • Intra peritoneal metastasis

  19. 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

  20. Case 60 • A middle age woman with chronic abdominal pain and weight loss. • You see the CT scan of patient in next slides.

  21. 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, Physical examination: Conscious, cooperative

  22. 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

  23. AST = 49 U/L ALT = 42 U/L Alkaline phosphatase = 769 U/L CEA & CA 19-9 > 3 Upper limit normal range Amylase = 100 T= 1.2 Bilirubin mg/dl D=0.8

  24. What is your diagnosis? • Pancreatic abscess • Acute mild pancreatitis • Pancreatic pseudocyst • Chronic pancreatitis • Necrotizing pancreatitis • Pancreatic cyst adenocarcinoma

  25. 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

  26. Case 61 • A middle age woman with epigastric pain. • You see the CT scan of patient in next slides.

  27. T (oral) = 39.5°c 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, Physical examination: Conscious, cooperative

  28. 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

  29. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 969 U/L Tumor markers = negative Amylase = 1000 T= 3.2 Bilirubin mg/dl D=1.8

  30. What is your diagnosis? • Pancreatic abscess • Acute mild pancreatitis • Pancreatic pseudocyst • Chronic pancreatitis • Necrotizing pancreatitis • Pancreatic cyst adenocarcinoma

  31. 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

  32. Case 62 • A middle age woman with epigastric pain and shock. • You see the CT scan of patient in next slides.

  33. T (oral) = 37.5°c 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, Physical examination: Conscious, cooperative

  34. 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

  35. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 969 U/L Tumor markers = negative Amylase = 1000 T= 3.2 Bilirubin mg/dl D=1.8

  36. What is your diagnosis? • Pancreatic abscess • Hemorrhagic pancreatic pseudocyst • Pancreatic pseudocyst • Chronic pancreatitis • Necrotizing pancreatitis • Pancreatic cyst adenocarcinoma

  37. 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

  38. 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.

  39. 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, Physical examination: Conscious, cooperative

  40. 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

  41. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 969 U/L Tumor markers = negative Na = 145 mEq/l K= 4.5 mEq/L T= 3.2 Bilirubin mg/dl D=1.8

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