Gastrointestinal System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S29_F1.jpg"}},{"insert":"\n\n\u0022Occam\u0027s razor \u2013 that\u0027s what I follow. How often in your career do you see truly \u0027rare\u0027 diseases? Pretty much never,\u0022 you hear a colleague say.\n\n\u0022Remember Hickam\u0027s dictum! What if you do get that one patient in a million? You need to keep an open mind,\u0022 another colleague retorts.\n\nAttempting to relax in the on-call room, you wish that they\u0027d just shut up so that you can have your dinner in peace. Unfortunately, your pager buzzes a few seconds later. You\u0027re needed in the ED. Putting your dinner aside, you quickly rush over there.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S29_F2.jpg"}},{"insert":"\n\nArriving at the ED, you are taken to see a middle-aged man.\n\nLucas is a 56-year-old widowed college professor. His daughter, who lives separately, called emergency services around 20 minutes ago, after visiting his house and finding him writhing on the ground in pain, clutching his abdomen.\n\nWhen emergency services arrived, they noted bloodstains around his mouth, on the front of his shirt, and on the ground nearby. His pulse was 116 bpm, blood pressure was 90\/55 mmHg, respiratory rate was 36\/min, and GCS was 14\/15 (M5-V5-E4).\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S29_F3.jpg"}},{"insert":"\n\nEn-route to the hospital, Lucas was started on oxygen via face mask and IV crystalloids. His pulse and blood pressure have now stabilized to 90 bpm, 110\/75 mmHg, and 16 respiratory cycles\/min. Multiple ECGs are completely normal.\n\nYou attempt to elicit a history, but Lucas only moans in response. A quick perusal of his medical records (which his daughter had the foresight to bring along) shows that he was diagnosed with peptic ulcer disease (PUD) by his primary care physician around 3 months ago, and started on omeprazole 20 mg bd. He has no other "},{"insert":"comorbidities","attributes":{"color":"#000000","background":"transparent"}},{"insert":".\n\nHis daughter tells you that her father was in general good health other than the PUD; and that he drank only socially and never smoked.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/S29_F2.jpg"}},{"insert":"\n\nExamination of the abdomen reveals generalized tenderness with guarding and rigidity. Examination of the other systems reveals no abnormalities. \n\nHis random plasma glucose is 89 mg\/dL. A standard panel of blood tests is sent off.\n"}]}


{"ops":[{"insert":"What do you think the most likely diagnosis is?\n"}]}
1. Boerhaave syndrome
2. Variceal hemorrhage
3. A perforated peptic ulcer