leviathan Posted September 2, 2010 Report Share Posted September 2, 2010 Instead of cluttering the forum with lots of questions, let's put cases in this thread. A 34-year-old man is admitted to the hospital with jaundice. He has a 12-year history of ulcerative colitis. Ultrasound of the right upper quadrant shows a large extrahepatic bile duct diameter and no gallstones. Liver biopsy shows a large bile duct obstruction. Which of the following findings is most likely on ERCP? A. Alternating constriction and dilation of intrahepatic bile ducts B. Markedly dilated common bile duct containing irregular radiolucent masses C. Mass at the ampulla of Vater D. Moderately dilated intrahepatic bile ducts and stricture in the bile duct at the porta hepatis E. Severely dilated biliary tree terminating in a blunt, nipple-like obstruction at the lower end of the common bile duct Link to comment Share on other sites More sharing options...
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JewelLeigh Posted September 4, 2010 Report Share Posted September 4, 2010 He likely has sclerosing cholangitis, so my guess is A or possibly D. Link to comment Share on other sites More sharing options...
A-Stark Posted September 4, 2010 Report Share Posted September 4, 2010 I'd say PSC as well, so A. Link to comment Share on other sites More sharing options...
leviathan Posted September 6, 2010 Author Report Share Posted September 6, 2010 Yep, it is PSC, answer is A. 2/3 of people with PSC have a history of colitis. "The disease is characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, producing alternating strictures and dilatation. These changes are seen as 'beading' on ERCP." B describes gallstones in the biliary tree C describes findings of carcinoma of the ampulla of Vater D describes the findings associated with carcinoma of extrahepatic bile ducts. E describes pancreatic carcinoma Link to comment Share on other sites More sharing options...
leviathan Posted September 26, 2010 Author Report Share Posted September 26, 2010 I like this Q. A 30 year old African-American female presents to your clinic with a fever and throat pain. She has a history of hyperthyroidism which is being medically managed. She is febrile with a mildly elevated heart rate, all other vitals wnl. On physical exam you find no significant findings. Which is the next appropriate step? A. TSH and T3/T4 levels B. ESR and P-ANCA, C-ANCA levels C. Empiric antibiotic therapy D. WBC count w/ differential E. Acetaminophen and oral hydration Link to comment Share on other sites More sharing options...
MDStudent Posted October 2, 2010 Report Share Posted October 2, 2010 I'd go with "D"...my thinking is that one of the more serious risks associated with pharmco mngt of hyperthyroidism is agranulocytosis, and we should rule that out first. Link to comment Share on other sites More sharing options...
MDStudent Posted October 2, 2010 Report Share Posted October 2, 2010 Thought I'd add a new case...it's a bit long, but has a neat 'twist'...enjoy! A 56-year-old man is evaluated for anorexia and a 5-kg (11-lb) unintentional weight loss over the preceding 4 months. He has vague abdominal discomfort and occasional flank pain. On physical examination, the BMI is 27 and the blood pressure is 108/72 mm Hg. Examination is unremarkable. CT scan of the abdomen shows a 6-cm left adrenal mass. Attenuation value of the mass is 32 Hounsfield units. The margins of the lesion are irregular and the consistency is heterogeneous. Radiographic evaluation of the lungs and kidneys reveals no other abnormality. Plasma fractionated metanephrines are normal. Plasma aldosterone/plasma renin activity (ARR) is 6 (normal <12). Serum cortisol at 0800 hrs after dexamethasone 1 mg the preceding evening is 1.4 µg/dL (38.63 nmol/L). Which of the following is the most appropriate next step in the management of this patient? A. Selective adrenal venous sampling B. Repeat biochemical testing and CT in 6 months C. Iodocholesterol imaging of adrenals D. Referral for surgical resection of mass Link to comment Share on other sites More sharing options...
leviathan Posted October 5, 2010 Author Report Share Posted October 5, 2010 I'd go with "D"...my thinking is that one of the more serious risks associated with pharmco mngt of hyperthyroidism is agranulocytosis, and we should rule that out first. Good call, good call. Methimazole and propylthiouracil both cause agranulocytosis in a small % of patients and is something you need to rule out in someone presenting like that. D is right. Link to comment Share on other sites More sharing options...
leviathan Posted October 5, 2010 Author Report Share Posted October 5, 2010 Thought I'd add a new case...it's a bit long, but has a neat 'twist'...enjoy! A 56-year-old man is evaluated for anorexia and a 5-kg (11-lb) unintentional weight loss over the preceding 4 months. He has vague abdominal discomfort and occasional flank pain. On physical examination, the BMI is 27 and the blood pressure is 108/72 mm Hg. Examination is unremarkable. CT scan of the abdomen shows a 6-cm left adrenal mass. Attenuation value of the mass is 32 Hounsfield units. The margins of the lesion are irregular and the consistency is heterogeneous. Radiographic evaluation of the lungs and kidneys reveals no other abnormality. Plasma fractionated metanephrines are normal. Plasma aldosterone/plasma renin activity (ARR) is 6 (normal <12). Serum cortisol at 0800 hrs after dexamethasone 1 mg the preceding evening is 1.4 µg/dL (38.63 nmol/L). Which of the following is the most appropriate next step in the management of this patient? A. Selective adrenal venous sampling B. Repeat biochemical testing and CT in 6 months C. Iodocholesterol imaging of adrenals D. Referral for surgical resection of mass This guy has no signs of catecholamine production, a normal dxm suppression test, and normal aldosterone levels, so I don't see how A,or C would help unless he had physical findings that suggested otherwise and you wanted to make sure you weren't missing a hormone-secreting tumor. It could be an early tumor of the adrenal that hasn't started secreting yet so you could wait (option , but given the heterogenous/malignant appearance on CT scan and the constitutional symptoms/weight loss, I'd be worried about a malignant adrenocortical carcinoma, play it safe and chop it out right aways, so option D. Link to comment Share on other sites More sharing options...
cheech10 Posted October 5, 2010 Report Share Posted October 5, 2010 This guy has no signs of catecholamine production, a normal dxm suppression test, and normal aldosterone levels, so I don't see how A,or C would help unless he had physical findings that suggested otherwise and you wanted to make sure you weren't missing a hormone-secreting tumor. It could be an early tumor of the adrenal that hasn't started secreting yet so you could wait (option , but given the heterogenous/malignant appearance on CT scan and the constitutional symptoms/weight loss, I'd be worried about a malignant adrenocortical carcinoma, play it safe and chop it out right aways, so option D. Agree. Big tumour and no clinical or lab evidence of pheo = go directly to surgery. Link to comment Share on other sites More sharing options...
adumpol Posted October 7, 2010 Report Share Posted October 7, 2010 There's a triage before patients are scheduled. Usually you speak with a nurse who works with you and the doctor to see how long you'll need, tests you might need, preparation you might need to undergo. Link to comment Share on other sites More sharing options...
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