#Ulcerative_colitis
#UC
#Osmosis

📌 Causes, symptoms, diagnosis, pathology and treatment

#Clinical_case #24

A 42 year old man comes to hospital with complaint of severe right knee pain, lasted for 8 hours. He states that the pain which started abruptly at 1AM and woke him from sleep, was quite severe, so painful that even the weight of the bed sheet was unbearable on his knee. By the morning, the knee had become warm, swollen and tender. He notices that he prefers to keep his knee bent, and extending his leg to straighten the knee cause the pain to worsen. He did some pain a year ago which was not as severe as this episode and resolved in 3 days after taking ibubrofen.

PMH 👉 Hypertension

S.H 👉 He works as a financial analyst. married

D.H 👉 Hydrochlorothiazide

H.H 👉 Negative

Ph.E 👇

Head and neck 👉 unremarkable

Chest 👉 clear on auscultation

Heart 👉 Tachycardic but regular with no gallops or murmurs

Extremities 👉 swollen right knee with a moderate effusion, and appears erythematous, warm, and very tender to palpitation

Skin 👉 No rashes

Vital signs:

BP = 135/78mmHg
PR = 102/min
RR = 17/min
T = 38°c

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1⃣ Most likely diagnosis?

2⃣ Next step?

3⃣ Best initial treatment?

#Clinical_case_answer #24

1⃣ Most likely diagnosis:

Acute monoarticular arthritis - Gout

🔴 Discussion:

A middle-aged man presents with an acute attack of monoarticular arthritis as evidenced by:
👉 Knee effusion
👉 Limited range of motion
👉 Signs of inflammation
The two most likely causes are:
1) Crystalline arthritis (e.g, gout or pseudogout)
2) Infections
The previous less severe episode involving his first metatarsophalangeal (MTP) joint sounds like podagra, the most common presentation of gout. The previous attack of arthritis in the first MTP joint and the very rapid onset of severe symptoms during the current attack are consistent with acute gouty arthritis.

🔔 Definitions:

📌 MONOARTHRITIS: Inflammation of a single joint.
📌 GOUT: A disturbance of uric-acid metabolism occurring mainly in men, characterized by painful inflammation of the joints, especially of the feet and hands, and arthritic attacks resulting from elevated levels of uric acid in the blood and the deposition of urate crystals around the joints.

Gout most commonly involves the first MTP joint (podagra), ankle, mid-foot, or knee. Pseudogout most commonly affects the large joints, such as the knee; it may also affect the wrist or the first MTP joint (hence, the name pseudogout).

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2⃣ Next step:

Aspiration of the knee joint to send fluid for:
👉 cell count
👉 culture
👉 crystal analysis

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3⃣ Best initial treatment:

1) If infection identified:
Drainage of the infected fluid by aspiration+ Antibiotics

2) If analysis is suggestive of crystal-induced arthritis:
Colchicine+ NSAID or corticosteroids

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✅ Final diagnosis:

#Acute_gout

📌 Joint aspirate characteristics

#Clinical_case #25

A 31-year-old G5P4 woman at 33 weeks’ gestation complains of significant bright red vaginal bleeding.She denies uterine contractions, leakage of fluid, or trauma.The patient states that 4 weeks previously, after she had engaged in sexual intercourse, she experienced some vaginal spotting.

PMH 👉 Negative

A.H 👉 Negative

Ph/E 👇

Heart 👉 Normal

Lung 👉 Clear on auscultation

Abdomen and uterus 👉 Soft and nontender

📌 Vital signs:

BP=110/70 mm Hg
HR=80 beats per minute
RR=18/min
T=37.2°
FHR= 144bpm

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1⃣ Most likely diagnosis?

2⃣ Next step?

3⃣ Long-term management?

#Clinical_case_answer #25

1⃣ Most likely dignosis:

Placenta previa

This patient is experiencing antepartum vaginal bleeding (bleeding after 20 weeks’ gestation). Because of the painless nature of the bleeding and lack of risk factors for placental abruption, this case is more likely to be placenta previa, defined as the placenta overlying the internal os of the cervix.The history of postcoital spotting earlier during the pregnancy is consistent with previa because vaginal intercourse may induce bleeding .

Placental abruption (premature separation of the placenta) 👉 usually is associated with painful uterine contractions or excess uterine tone.

🔴 Definitions:

ANTEPARTUM VAGINAL BLEEDING 👉 Vaginal bleeding occurring after 20 weeks gestation.
PLACENTA PREVIA 👉 The placenta completely covers the internal os of the uterine cervix
MARGINAL PLACENTA PREVIA 👉 The placenta lies within 2 cm of the internal os of the cervix, but does not fully cover it.
LOW-LYING PLACENTA 👉 The edge of the placenta is within 2 cm of the internal cervical os.
PLACENTAL ABRUPTION 👉 Premature separation of a normally implanted placenta.
VASA PREVIA 👉 Umbilical cord vessels that insert into the membranes with the vessels overlying the internal cervical os, thus being vulnerable to fetal exsanguination upon rupture of membranes

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2⃣ Next step:

Ultrasound examination 👉
Ultrasound is an accurate method of assessing placental location.At times,transabdominal sonography may not be able to visualize the placenta, and transvaginal ultrasound is necessary and is more reliable for visualizing the internal cervical os.

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3⃣ Long term management:

Expectant management as long as the bleeding is not excessive. Cesarean delivery at 34 weeks’ gestation .

⚠️ Risk factors for placenta previa:

👉 Grand multiparity
👉 Prior cesarean delivery
👉 Prior uterine curettage
👉 Previous placenta previa
👉 Multiple gestation

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✅ Final diagnosis:

#Placenta_previa

📌 Types of placenta previa

A 👉 Complete
B 👉 Marginal
C 👉 Low-lying placentation

🔔🔔🔔🔔

Hello friends!

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📌 Your patient's education
📌 Overview of common diseases
📌 Newest methods of treatments
📌 Diagnosis and etiologies of diseases

In addition, you are welcome to suggest any subject that you want to learn more about

✅ Our purpose is to provide videos to educate patients based on the latest medical references.


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👇👇👇👇

https://youtu.be/QQ-1wVrnKRQ

#Clinical_case 26

A 36-year old man has came to the office complaining of some red, painful and fluid-filled lesions on his right arm which has started from 5 days ago. The pain is getting worse over time passing. Today some new lesions have appeared around his right eye which is itchy and painful. He notices no more complaints.

PMH 👉 Negative

D.H 👉 Negative

Physical examinations:

There are some red blisters on lateral part of his right arm and also his right eye which is tender in touch.
Neurological examinations of both eyes are intact.

📌 Vital signs 👉 Normal

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1⃣ What is the most likely diagnosis?

2⃣ What else do you need to know about his history?

3⃣ Management?

4⃣ What would you tell your patient as part of "patient education"?

@Clinical_case_answer 26

#Clinical_case 27

A 54 year old man presents to your office complaining of chronic fatigue and feeling of tireness that has been started since 2 months ago. He also complains of abdominal pain especially in the epigaster and RUQ that happens sometimes, with nausea and decreased appetite. He has last weight for about 5Kg over recent 2 months.

👉 PMH:

1) DM2 (from 12 years ago)
2) Hypercholesterolemia

👉 D.H:

1) Metformin 1000mg daily
2) Rosuvastatin 20mg daily

Physical examination:

Head and neck 👉 Both sclera are a bit icterous

Skin 👉 Normal color and turgor

Chest 👉 Normal

Abdomen 👉 No tender/ No distention

Extremities 👉 Normal

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1⃣ Differential diagnosis?

2⃣ Most likely diagnosis?

3⃣ Management?

#Clinical_case_answer 27

1⃣ Differential diagnosis:

1) Nonalcoholic fatty liver disease (NAFLD)
2) Hepatocellular carcinoma
3) Hepatitis C
4) Pancreatic cancer
5) Choledocholithiasis
6) Starvation
7) Wilson disease
8) Liver cirrhosis
9) Abetalipoproteinemia
10) Cholangiocarcinoma

2⃣ Most likely diagnosis:

According to patient's age, long history of diabetes, decreased energy and appetite and vague abdominal pain, fatty liver can be suspected.
But weight loss of 5Kg and conjunctival jaundice, raise our suspicion of hepatic cancers.

3⃣ Management:

🔹Diagnosis of liver cancers as well as fatty liver disease is made by considering the patient's history and examinations, laboratory and paraclinical procedures.
The following tests should be requested in this patient:

📌 CBC diff
📌 PT, PTT, INR, Albumin
📌 AST, ALT, ALP, Bili (T & D)
📌 LDL, HDL, cholesterol & triglyceride
📌 Amylase, Lipase
📌 FBS
📌 Anti HCVAb
📌 HBsAg, HBcAg
📌 Plasma Iron, ferritin and TIBC
📌 Gamma glutamyl transferase
📌 Abdominal Ultrasound

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🔔 The definitive method for diagnosing in these patients is biopsy.
The patient eventually underwent a biopsy. The final diagnosis was high-grade fatty liver disease with no clue of cancer. The patient lost weight in the context of severe loss of appetite from two months ago.

In patients with fatty liver disease and risk factors such as weight loss and jaundice, complete hepatitis diagnostic tests should be performed and the following recommendations are essential:

1) Recommended to lose weight in obese patients
2) Avoid alcohol
3) Regular control of blood sugar under the supervision of a physician
4) Regular exercise program, at least 30 minutes daily

The main treatment in these patients lifystyle change, but in some references, some medications have been recommended, such as:

📌Vitamin E
📌Pioglitazone

In advanced cases, Liraglutide can be used to prevent liver fibrosis.
In case of impaired liver enzymes, the liver profile should be checked every three to six weeks until it becomes normal.

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✅ Final diagnosis:

#High_grade_fatty_liver_disease

#Clinical_case 28

A 47-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. She is married for 20 years.

PMH 👉 excessive blood loss in previous pregnancy, which required a blood transfusion

D.H 👉 Negative

H.H 👉 No smoking/ drinks occassionally/ Snored cocaine once or twice many years ago

📌 Physical examination:

Head and neck 👉 Sclerae are icteric

Chest 👉 Symmetric/ Clear to auscultation

Abdomen 👉 Swollen with mild diffuse tenderness/ distented/ Shifting dullness to percussion and a fluid wave/ Hypoactive bowel sounds

Extremities 👉 Normal


👉 Vital signs:

BP = 94/60 mmHg
PR = 88 bpm
RR = 18/min
T = 38°C

📌 Laboratory results:

Na = 129 mEq/L
Alb = 2.8 mg/dL
Total bilirubin = 4mg/dL
PTT = 15 sec
INR = 1
WBC = 5,600
Hgb = 12 g/dL
MCV = 102 fL
Plt = 78,000

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1⃣ Differential diagnosis?

2⃣ Most likely diagnosis?

3⃣ Next step?

#Clinical_case_answer 28

1⃣ Differential diagnosis:

1) High grade fatty liver disease
2) Cirrhosis
3) Hepatocellular carcinoma
4) Hepatitis
5) Hemochromatosis
6) Wilson's disease

2⃣ Most likely diagnosis:

👉 "Hepatic cirrhosis"

Clinical approach:

Cirrhosis is the end result of chronic hepatocellular injury that leads to both fibrosis and nodular regeneration. With ongoing hepatocyte destruction and collagen deposition, the liver shrinks in size and becomes nodular and hard. Alcoholic cirrhosis is one of the most common forms of cirrhosis. It is related to chronic alcohol use, but there appears to be some hereditary predisposition to the development of fibrosis, and the process is enhanced by concomitant infection with hepatitis C. Clinical symptoms are produced by the hepatic dysfunction as well as by portal hypertension, which is produced by increased resistance to portal blood flow, producing portal hypertension, and sometimes to resultant portosystemic shunting. Loss of functioning hepatic mass leads to jaundice as well as impaired synthesis of albumin (leading to edema) and of clotting factors (leading to coagulopathy). Fibrosis and increased sinusoidal resistance lead to portal hypertension and its complications, such as esophageal varices, ascites, and hypersplenism. Portosystemic shunting via natural collaterals or iatrogenic shunts causes hepatic encephalopathy. Portal hypertension causes caput medusa and hemorrhoids. Decreased liver production of steroid hormone binding globulin (SHBG) leads to an increase in unbound estrogen manifested by spider angioma, palmar erythema and gynecomastia

3⃣ Next step:

Paracentesis of ascitic fluid (to determine its likely etiology as well as evaluate for the complication of SBP)

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✅ Final diagnosis:

#Cirrhosis probably hepatitis C-related

📌 Complications of cirrhosis