Monday 29 October 2012
Wednesday 24 October 2012
CME- CASE OF THE WEEK FROM MEDSCAPE EDUCATION
STUDENTS ARE WELCOME TO PARTICIPATE THE CME CASE OF THE WEEK
On admission, the patient appears to be a frail, pale, and malnourished elderly woman. Her vital signs are a heart rate of 106 beats/min, temperature of 98.9°F (37.2º C), blood pressure of 156/76 mm Hg, and respiratory rate of 14 breaths/min. Examination of the head and neck is normal. Pulmonary auscultation reveals normal breath sounds bilaterally. The cardiac rhythm is regular and there is a grade II/VI systolic murmur present at the base. Her abdomen is soft and without distention or tenderness. No hepatosplenomegaly is appreciated. The rectal examination is unremarkable except for brown, heme-positive stool. There is no edema present in her extremities.
Laboratory analysis reveals a white blood cell count of 9400/mm3 (normal range, 4500-11,000/mm3), hemoglobin of 6.8 g/dL (normal range, 12.0-16.0 g/dL), mean corpuscular volume of 63 fL (normal range, 80-100 fL), ferritin of 86 ng/mL (normal range, 12-150 ng/mL), and platelets of 644,000/mm3 (normal range, 150,000-400,000/mm3). The results of the basic metabolic panel are within normal limits. The patient receives 2 units of packed red blood cells and undergoes endoscopic evaluation. Esophagogastroduodenoscopy and colonoscopy fail to expose a bleeding source. Capsule endoscopy is then performed and is reported as normal. Subsequent abdominal CT scanning shows asymmetric nodular wall thickening of a short segment of the mid/distal jejunum. This loop of the jejunum is abnormally dilated, measuring up to 4 cm in diameter (Figure 1). In light of these radiologic findings, the small bowel capsule endoscopy images are reviewed again at a lower speed. Guided by the CT results, the review focuses on the jejunal images. After careful examination, a lesion is indeed seen in a location compatible with the one outlined by the CT scan (Figure 2). The patient is then referred for surgery.
A 73-Year-Old Woman With Generalized Weakness and Heme-Positive Stool CME
CME Released: 08/03/2011; Reviewed and Renewed: 10/24/2012; Valid for credit through 10/24/2013
Background
A 73-year-old woman is referred to the hospital for evaluation of iron-deficiency anemia and heme-positive stool. She has a history of hypertension, hypercholesterolemia, and lobular breast carcinoma for which she underwent a modified right mastectomy 3 years ago. The patient complains of generalized weakness and lack of appetite. She denies any history of shortness of breath, chest pain, nausea, vomiting, obstipation, hematemesis, hematochezia, or melena. Her medications at the time of admission include amlodipine, valsartan, and simvastatin. There is no history of tobacco, alcohol, or illicit drug use. She is not taking any nonsteroidal anti-inflammatory drugs (NSAIDs).
On admission, the patient appears to be a frail, pale, and malnourished elderly woman. Her vital signs are a heart rate of 106 beats/min, temperature of 98.9°F (37.2º C), blood pressure of 156/76 mm Hg, and respiratory rate of 14 breaths/min. Examination of the head and neck is normal. Pulmonary auscultation reveals normal breath sounds bilaterally. The cardiac rhythm is regular and there is a grade II/VI systolic murmur present at the base. Her abdomen is soft and without distention or tenderness. No hepatosplenomegaly is appreciated. The rectal examination is unremarkable except for brown, heme-positive stool. There is no edema present in her extremities.
Laboratory analysis reveals a white blood cell count of 9400/mm3 (normal range, 4500-11,000/mm3), hemoglobin of 6.8 g/dL (normal range, 12.0-16.0 g/dL), mean corpuscular volume of 63 fL (normal range, 80-100 fL), ferritin of 86 ng/mL (normal range, 12-150 ng/mL), and platelets of 644,000/mm3 (normal range, 150,000-400,000/mm3). The results of the basic metabolic panel are within normal limits. The patient receives 2 units of packed red blood cells and undergoes endoscopic evaluation. Esophagogastroduodenoscopy and colonoscopy fail to expose a bleeding source. Capsule endoscopy is then performed and is reported as normal. Subsequent abdominal CT scanning shows asymmetric nodular wall thickening of a short segment of the mid/distal jejunum. This loop of the jejunum is abnormally dilated, measuring up to 4 cm in diameter (Figure 1). In light of these radiologic findings, the small bowel capsule endoscopy images are reviewed again at a lower speed. Guided by the CT results, the review focuses on the jejunal images. After careful examination, a lesion is indeed seen in a location compatible with the one outlined by the CT scan (Figure 2). The patient is then referred for surgery.
What is the most likely etiology of the patient's gastrointestinal bleed?
Hint: Note the patient's medical history.
Hint: Note the patient's medical history.
Peptic ulcer disease
Arteriovenous malformation
Small bowel tumor
Meckel diverticulum
Gastritis
CME Test
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