Download CASES FOR SMALL GROUP SESSION

CASES FOR SMALL GROUP SESSION
ABDOMEN AND PELVIS
Monday, January 28, 2008 1-3PM
CASE 1
During a routine physical examination for the fall sport program, a 12 year-old seventh grade
male is found to have a walnut size enlargement just to the left of the pubic tubercle. On
questioning the boy relates that the enlargement seems to change in size depending on the body
position and level of activity. He explains that the enlargement is particularly obvious during
and immediately after his training sessions in the “weight room”. On the other hand, he says that
sometimes in the morning the enlargement is “barely noticeable”. Physical examination of the
external genitalia reveals that both testicles are of normal size and position. He has had no prior
surgery or illness and is not taking any medications.
PHYSICAL EXAMINATION OF THE PATIENT
Pulse:
Rhythm:
Temperature:
Respiratory rate:
Height:
Weight:
80
Regular
98.4oF.
15
5’6”
110 lbs.
HEENT Examination:
Lungs:
Cardiovascular:
Abdomen:
Normal
Normal
Normal
Normal, with the exception of a small palpable mass in the groin
region just lateral to the pubic tubercle.
Genitourinary Examination:
Normal
Musculoskeletal Examination:
Normal
Neurologic Examination:
Normal
Questions:
1.
2.
3.
4.
5.
Develop a list of possible causes for the enlargement.
Is this a congenital or acquired condition?
What is the anatomical basis for the condition?
What is your diagnosis?
What is your recommendation for this patient’s participation in sports?
CASE 2
A 62 year-old white male walks into the emergency center at 5:00 PM. He appears
apprehensive and uncomfortable; his body is bent forward. During the history he states that he
was sitting at his desk after lunch when a sharp (“stabbing”) pain came over him, beginning in
the RU quadrant and spreading over the LU quadrant all the way around to his back. The pain
was very intense for a few hours but now it is more of an ache that has spread all along the left
side of his abdomen. Any motion makes the pain worse. He has also noticed a pain in his left
shoulder. He has no history of previous abdominal pain, heart or lung disease. He is not taking
any medication and drinks a beer 2 to 3 nights a week. On further questioning, he says that he
has felt nauseous all day and in fact vomited right after the pain struck. In his words, “It looked
like I vomited coffee grounds.”
PHYSICAL EXAMINATION OF THE PATIENT
Vital signs:
Lying supine:
Standing:
Pulse:
Rhythm:
Temperature
Respiratory rate:
Height:
5’10”
Weight:
Blood pressure
135/80 left arm and 135/75 right arm
130/75 left arm and 130/70 right arm
95
Regular
100.5oF.
22
210 lbs.
HEENT Examination:
Normal
Lungs:
Normal
Abdomen:
Inspection, auscultation, percussion, and palpation of the abdomen
are normal except for the following findings. Auscultation reveals hypoactive bowel sounds.
There is guarding of the anterolateral abdominal wall, (but no rebound tenderness). The
epigastric and left hypochondriac regions are tender to deep palpation.
Musculoskeletal Examination: Inspection and palpation of the left shoulder region reveal the
following pertinent normal findings. Active and passive movements of the left arm and
isometric tests of the left arm movements involving the shoulder acromioclavicular, and
sternoclavicular joints are all normal and do not produce any change in left shoulder pain.
Neurologic Examination:
Normal
Questions:
1. What is guarding of the anterior abdominal wall?
2. Explain the source and distribution of the patient’s pain? What is significant about the pain in
his shoulder?
3. What is the significance of the “coffee grounds” in the vomitus?
4. What are the boundaries of the greater sac? the lesser sac?
5. What is your diagnosis?
CASE 3
A 45 year-old black woman walks into the emergency center. She appears apprehensive and
very uncomfortable; her body is bent slightly forward and to the right. She is complaining of
moderate abdominal pain, which has been increasing in intensity over the course of the last
several days. It began in the epigastric region about 5 days ago. The pain has been getting worse
each day and is now located in the RUQ, and in the back between the shoulders. The pain
“attacks” come an hour or so after meals. The pain is worse on deep inspiration. She has also
felt feverish, had chills, nausea and vomited twice the previous day. The sclera of her eyes is
moderately yellowish. She describes her urine as the color of “Coke”. She has had no prior
illness, is not taking any medications and may drink a beer with her husband on the weekends.
PHYSICAL EXAMINATION OF THE PATIENT
Vital signs:
Blood pressure
Lying supine:
120/65 left arm and 125/70 right arm
Standing:
105/55 left arm and 110/60 right arm
Pulse:
115
Rhythm:
Regular
Temperature:
103.8oF.
Respiratory rate:
22
Height:
5’8”
Weight:
180 lbs.
HEENT Examination:
Inspection of the oral cavity shows that the mucous membrane of
the hard palate is yellowish.
Lungs:
Normal
Cardiovascular Examination: The cardiovascular exam is normal except for the tachycardia and
the orthostatic changes in blood pressures.
Abdomen:
Inspection, auscultation, percussion, and palpation of the abdomen
are normal except for the following findings: Percussion shows that the combined heights of the
zones of hepatic dullness and hepatic flatness span a distance of 14 cm along the right
midclavicular line. Deep palpation reveals a firm, regular, smooth but tender liver edge palpable
below the right costal margin on inspiration. Fist percussion applied to the lower ribs above the
right costal margin elicits an increase in upper abdominal pain. The gallbladder is not palpable,
but Murphy’s sign (interruption of inhaled breath when the patient is palpated underneath the
right costal margin) is observed. Light and deep palpation elicit localized tenderness in the RUQ
only.
Genitourinary Examination:
Normal
Musculoskeletal Examination:
Normal
Neurologic Examination:
Normal
Questions:
1.
Explain the finding of the abdominal examination.
2.
Explain the source and distribution of the patient’s pain.
3.
Explain the significance of the yellowish sclera and the color of the urine.
4.
What would you expect radiographic evaluation of this patient to reveal?
CASE 4
A 66 year-old white man has made an appointment to seek treatment for a painful back. The
patient is overweight and appears uncomfortable. He is complaining of a pain in his lower back
that began about two months ago. He describes the pain as a “dull ache” which has not increased
in intensity and is not improved by changes in position. He has no history of injury or trauma.
He has a morning cough during which he produces yellowish sputum. He smokes 2 or 3 cigars a
day and has for ten years. He has had no recent change in bowel habits but he complains of
nocturia. He has had a recent weight loss (10 pounds in 2 months) but he has no history of
previous illness and is not taking any medications.
PHYSICAL EXAMINATION OF THE PATIENT
Vital Signs:
Lying supine:
Standing:
Pulse:
Rhythm:
Temperature:
Respiratory rate:
Height:
Weight:
Blood Pressure
135/90 left arm and 135/80 right arm
135/80 left arm and 135/80 right arm
75
Regular
98.4oF.
19
5’9”
225 lbs.
HEENT Examination:
Normal
Lungs:
Inspection, palpation, percussion, and auscultation of the lungs are normal except
for a few expiratory rhonchi throughout both lungs. The rhonchi are diminished
upon coughing.
Cardiovascular Examination: Normal
Abdomen:
Inspection, auscultation, percussion, and palpation of the abdomen are normal
except in the following findings. The rectal exam reveals a hard, irregular
painless nodule anteriorly in the midline.
Genitourinary Examination:
Normal
Musculoskeletal Examination:
Normal
Neurologic Examination:
Normal
Questions:
1.
What structures can normally be palpated during a rectal exam in the male? in the
female?
2.
What is the arterial blood supply to the prostate? What is the venous drainage? What is
the lymphatic drainage?
3.
Explain the source and distribution of the patient’s pain.
4.
What is your diagnosis?
CASE 5
A 26 year-old female with one healthy child has come to the OB/Gyn clinic with the compliant
of vaginal spotting and lower abdominal pain. Her medical history indicates a previous
pregnancy without incident and a pelvic infection three years prior to the pregnancy. She says
she has not had any significant vaginal discharge (other than the spotting), has had no recent
trauma and has not recently had intercourse.
PHYSICAL EXAMINATION OF THE PATIENT
Vital Signs:
Blood Pressure:
Pulse:
Rhythm:
Temperature:
Respiratory rate:
Height:
Weight:
90/60
110
Regular
98.6 oF.
17
5’3”
125 lbs.
HEENT Examination:
Lungs:
Cardiovascular Examination:
Abdomen:
Normal
Normal
Normal
Inspection, auscultation, percussion, and palpation of the abdomen
are normal and bowel sounds are present and normal.
Genitourinary Examination: On pelvic exam, external genitalia was normal and uterus was
palpable and normal. There is moderate tenderness in the right
lower quadrant of the abdomen.
Musculoskeletal Examination:
Normal
Neurologic Examination:
Normal
A transvaginal sonogram showed an empty uterus with free fluid in the “cul-de’sac”.
Questions:
1.
Where and what is the “cul’de’sac”? What does fluid in this areas mean?
2.
What structures can normally be palpated/viewed during a pelvis examination?
3.
What is the arterial blood supply to the uterus/uterine tube/ovary? What is the venous
drainage? What is the lymphatic drainage?
4.
Explain the source and distribution of the patient’s pain.
5.
What is your diagnosis?
6.
What other test(s) would you order to confirm your diagnosis?