miky
Forum Senior
Topics: 16
Posts: 99
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sorry abt. the previous test. Wrong title. I thought of sth. else.
55 yo male
History:
heavy smoker (20 cigs/day),
acute MI 5 yrs ago;
takes Aspirin 81mg/day;
does not drink.
Comes to the ER after 3 bouts of severe blood vomiting. He is pale, dizzy and diaphoretic. One day ago he sustained a severe blunt chest trauma which he ignored. Mild chest pain, especially in the back unrelated to exercise, rest, food, body position, breathing and non-radiating.
Physical:
BP = 100/ 60 supine, 70 / 50 orthostatism
HR = 140
RR = 28
upper limb pulse - rapid but present
lower limb pulse - unrecordable (can't feel)
Chest: clear lungs, trachea in the middle, 2/6 systolic murmur heard at the apex
Abdomen: unremarkable
The rest of the physical exam is unremarkable.
Lab:
CXR: normal
SaO2 = 90 %
AXR: normal
A NG tube is inserted and shows some blood in the stomach.
Endoscopy is then ordered and shows no abnormalities of lower esophagus, stomach or duodenum.
The patient vomits blood in front of your eyes for the 4th time; the blood is red;
The most probable dx is  :
The next investigation is 8) :
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always happy and ready to serve and help my friends and patients as well.
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| ELM
Forum Guru
Topics: 28
Posts: 936
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Where is the options?????????????????????
Don't wanna go on wild goose chase....give us the options! That's how we will get tested!
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ELM
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| yutaro
Forum Newbie
Topics: 5
Posts: 21
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I think this patient has two or three conditions for sever blood vomiting.
Chest trauma is the triger, isnt it?
Where is such a severe bleeding from,causing hypotension?
he is a very arthersclerotic man. No doubt he has a big aneurysm
of aortic arch.
Blunt trauma may make a minor blood leaking of big fragile anuerysm.
If it is very closely along upper esoophagus, it will make a fistula.
So bleeding is from a fistula between upper esophagus and Aorta.
This is my story. How about it?
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| miky
Forum Senior
Topics: 16
Posts: 99
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CONGRATULATIONS yutaro !!!!!!!!!!!!!!!!!! 8)
CORRECT DIAGNOSIS
Despite what ELM wants :cry: . Dear ELM, the Dx was quite easy and you should have guessed it w/o any choices :wink: .
Yes, it's aorto-esophageal fistula. Most probably due to aortic aneurysmal rupture and a tear in the esophagus that was not identified on endoscopy (I mentioned normal lower esophagus, but not middle and upper segments).
Next investigation: Angiography (gold standard)
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always happy and ready to serve and help my friends and patients as well.
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| ELM
Forum Guru
Topics: 28
Posts: 936
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It's nice of you posting qs and discussing with others i appreciate your contribution here (dear) Miky, but i will be more happy if you put the options down when you post qs....even your qs are pretty obvious. Again that's how we will get tested....just wanted you to know. You can do whatever you wanted, we still be thankful for you ...but please now on.
Thank you.
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ELM
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| miky
Forum Senior
Topics: 16
Posts: 99
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ELM,
I know how we are tested in the real exams. I have already given step 1 & step 2CK and I achived truly competitive scores: step 1 - 252/ 96+, step 2CK - 247 / 95. Despite my high scores, I do not want to boast of it :wink: .
I chose not to give you options because I want to make you think on the case . I do not know whether you are practicing medicine or not, but I am now working in the ER and believe me or not, I would see many emergencies every day. The problem is that nobody gives you "options / answers" from which you may chose :wink: . You must rely entirely on your medical knowledge and clinical skills to be able to secure a dx in due time (before pt. leaves this world) .
The cases I've presented to you resemble quite well the cases I would encount every day in the ER 8) . Some of them are truly demanding and that is why I've decided to post them on this site .
I hope I did not make you feel upset about me. You should know one thing: "Only God cures people; we doctors treat them" :idea: .
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always happy and ready to serve and help my friends and patients as well.
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| ELM
Forum Guru
Topics: 28
Posts: 936
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Congratulations Miky,
I got bit confused...I thought 99 starts from 244 or 245.....how did you get 252/96? Anyway, never thought a practising physician would hung out on the forums like this...this is quite unusuall.But good to know....perhaps i will be hanging out here between my breaks during my residency  ....but i doubt though. :!:
Thank for helping us here then!
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ELM
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| miky
Forum Senior
Topics: 16
Posts: 99
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ELM,
My scores are on the papers they sent me. If they made a mistake, that's their problem, not mine. This is what they sent me. Do you contradict them? And frankly, I don't give a .... pin on what they sent me...the first score matters most, not the percentile. As for 99+ starting from 244, check it again...maybe you missed the math or statistics class. Have a nice day. There are doctors in the world as well prepared or even better prepared than us or canadian doctors.
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always happy and ready to serve and help my friends and patients as well.
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| yutaro
Forum Newbie
Topics: 5
Posts: 21
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Like this case,
interventional radiologists must struggle for stopping bleeding using metalic stent. Even if they can do intervention successfully, stenting may produce another fistula.
Angiography plays a role in diagnosis and treatment
but Lately multislice CTs are able to efficiently make anatomy of fistula clear with techniques of reconstruction.
I experienced some cases like that.
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