A.W.K Medical Cases

A 46-year-old woman presents with sudden-onset dyspnea and pleuritic chest pain 10 days after hip surgery. She is distressed and diaphoretic. BP is 76/48 mmHg, HR 132/min, and SpO₂ is 84% on room air. Bedside echocardiography shows right ventricular dilatation and strain. What is the most appropriate immediate treatment? A. Oral apixaban B. IV unfractionated heparin alone C. Systemic thrombolysis D. CT pulmonary angiography E. Inferior vena cava filter

Ans:C This is cardiac tamponade causing obstructive shock. The classic findings are hypotension, raised JVP, and muffled heart sounds (Beck’s triad). Echo evidence of chamber collapse supports the diagnosis. Definitive emergency treatment is urgent drainage of the pericardial fluid.

A 48-year-old woman with metastatic malignancy presents with progressive dyspnea and dizziness. BP is 78/50 mmHg, HR 124/min. Examination reveals elevated JVP and muffled heart sounds. Her lungs are clear. Bedside echocardiography shows a large pericardial effusion with right ventricular diastolic collapse. What is the most appropriate immediate management? A.IV dobutamine infusion B. IV nitrate infusion C. Emergency pericardiocentesis D. Non-invasive ventilation E. IV norepinephrine infusion

The combination of chronic fatigue, weight loss, postural symptoms and hyperpigmentation, together with hyponatremia, hyperkalemia and hypoglycemia, strongly suggests primary adrenal insufficiency (Addison disease). The acute GI illness has precipitated an adrenal crisis, evidenced by profound hypotension and altered mental status. Immediate treatment is IV/IM hydrocortisone + rapid IV isotonic saline. B/Z she is hypoglycemic, IV dextrose should also be given. Treatment should not be delayed while waiting for cortisol or ACTH results

A 35-year-old woman presents to the emergency department after 2 days of vomiting and diarrhea. She reports several months of progressive fatigue, weight loss, and dizziness on standing. Examination reveals diffuse hyperpigmentation, particularly over the palmar creases and oral mucosa. She is confused and severely weak. BP is 72/40 mmHg. Laboratory investigations show: Na⁺ 124 mmol/L K⁺ 6.0 mmol/L Glucose 54 mg/dL What is the most appropriate immediate treatment? A. Oral fludrocortisone B. IV hydrocortisone and isotonic saline C. IV insulin alone D. IV levothyroxine E. IV isotonic saline and dextrose alone

Ans:B ‼️Severe hypotension, tachycardia, and a positive FAST suggest life-threatening intra-abdominal hemorrhage. Resuscitation with blood products and urgent hemorrhage control are essential. CT should not delay surgery in a persistently unstable patient with suspected intra-abdominal bleeding.

30-year-old man is brought to the ED after a road traffic accident. His HR is 142/min, BP is 75/40 mmHg, and his abdomen is distended. FAST is positive for free fluid. What is the most appropriate next step? A. CT abdomen with contrast B. Immediate laparotomy with blood product resuscitation C. Observe after 1 L of crystalloid D. Start dopamine infusion as first-line treatment E. Perform diagnostic peritoneal lavage

Ans: C 🌟This is a case of a strangulated inguinal hernia, suggested by the transition from colicky to continuous pain, tachycardia, and involuntary guarding. Initial resuscitation includes IV fluids, analgesia, and broad-spectrum antibiotics, without delaying surgery for imaging when peritonitis is evident. Urgent surgical exploration is required, and manual reduction is contraindicated when strangulation is suspected.

A 67-year-old man presents with a 10-hour history of colicky abdominal pain and vomiting. Examination reveals a tender, irreducible right groin swelling. His pain has now become continuous, and he develops tachycardia and abdominal guarding. What is the most appropriate next step? A. Attempt manual reduction under sedation B. Perform urgent CT before deciding on treatment C. Urgent surgical exploration after initial resuscitation D. Insert a nasogastric tube and observe for 24 hours E. Perform elective hernia repair after resolution of symptoms

Ans: B. Sigmoid volvulus The coffee-bean sign results from twisting of the sigmoid colon around its mesentery. It causes large bowel obstruction ,in this case urgent endoscopic detorsion is the initial treatment if there is no ischemia, perforation, or peritonitis. Emergency surgery is required if any of these complications are present, and definitive sigmoid colectomy is recommended to prevent recurrence. ‼️Unlike sigmoid volvulus, cecal volvulus generally requires surgery as the initial treatment.

A60-year-old male presents with abdominal distension and constipation. An abdominal X-ray is performed, as shown in this image What is the most likely diagnosis? A. Cecal carcinoma B. Sigmoid volvulus C. Small bowel adhesions D. Intussusception E. Paralytic ileus

Ans: E. pancreatic pseudocyst is a collection of pancreatic fluid enclosed by a fibrous wall, developing approximately 4–6 weeks after acute pancreatitis due to pancreatic duct disruption or enzyme leakage. It may present as a palpable epigastric mass, even in an asymptomatic patient. Unlike a true cyst, it lacks an epithelial lining.

وزاري 2024 A 42-year-old man had an acute pancreatitis 6 weeks ago. He attends the surgical clinic for follow-up. During examination you felt a palpable mass in the epigastric area. The patient denies any symptoms and he is feeling well since his pancreatitis attack. Vital signs are stable. The most likely provisional diagnosis is: a. Palpable stomach cancer b. Cystadenoma of the pancreas c. Palpable liver edge d. Pancreatic malignancy e. Pancreatic pseudocyst