تشخیص بالینی گام به گام

نوع مقاله: مقاله پژوهشی

نویسندگان

1 استاد بیماریهای داخلی، دانشگاه علوم پزشکی مشهد، مشهد، ایران

2 استادیار بیماریهای گوارش وکبد بالغین، دانشگاه علوم پزشکی مشهد، مشهد، ایران

3 استادیار گروه روانپزشکی، مرکز تحقیقات روانپزشکی و علوم رفتاری، دانشگاه علوم پزشکی مشهد، مشهد، ایران

4 فلوشیب بیماریهای گوارش وکبد بالغین، دانشگاه علوم پزشکی مشهد، مشهد، ایران

چکیده

مردی 46 ساله با سابقه اسهال متناوب ده ماهه که فواصل اسهال و توقف آن از نظر زمانی کوتاه‌تر شده است، به علت اسهال شدید و عدم بهبودی به اورژانس بیمارستان مراجعه می نماید.
در بررسی بالینی بیمار هوشیار و از سردرد، تهوع و اسهال آبکی فراوان شاکی بود. همکاری لازم برای ارائه‌ی شرح حال نداشت و کم حوصله و تحریک‌پذیر بود. در بررسی علایم حیاتی 80/120BP= میلی‌متر جیوه ودرجه حرارت دهانی  8/36، تعدادضربان قلب 90 در دقیقه وسمع قلب و ریه طبیعی بود. ارگانومگالی در لمس شکم و ورم اندام تحتانی نداشت. دهیدراتاسیون در حد متوسط ارزیابی شد. در بررسی آزمایشگاهی  نتایج زیر مشاهده گردید:
 
 





FBS=135 mg/dl


PT=11.5 sec


WBC=11.6*103/ml




Bun=55 mg/dl


PT Activity=100%


Hemoglobin=16.2 g/d




Cr=3 mg/dl


PT control=11.5


HCT=49.7%




AST=95 IU/L


INR=1


Plt=324*103 Tbo/ul




AlT=90 IU/L


PTT=26 sec


Neutr=74%




ALP=190 IU/L


ESR 1st hr =14mm


Lymph=18%




Bili (T)=2.5 mg/dl


ESR2nd hr=29mm


Mono=4%




Bili (D)=0.3 mg/dl


Na=149mEq/dl


Eos=4%




LDH=548 IU/L


K=3.9mEq/dl


 

عنوان مقاله [English]

Step by Step Clinical Diagnosis

نویسندگان [English]

  • Mahmoud Farhoudi 1
  • Ali Mokhtarifar 2
  • Amir Rezaee Ardani 3
  • Hamidreza Zivarifar 4
1 - Professor of Internal Disease, Mashhad University of Medical Sciences, Mashhad,
2 Assistant professor of gastrointestinal disease, Mashhad University of Medical Sciences, Mashhad,
3 Assistant Professor of psychiatry, Mashhad University of Medical Sciences, Mashhad,
4 Fellowship in gastrointestinal disease, Mashhad University of Medical Sciences, Mashhad,
چکیده [English]

A 46 years old gentleman was admitted to hospital following a 10 months history of sever diarrhea. On examination, the patient appeared as mildly dehydrated though his vital sings were within normal limits.important result tests were:
 





Bun=55 mg/dl       Na=149 mEq/dl          WBC=11.6*103/ml           Hemoglobin=16.2 g/d    




Cr=3 mg/dl                K=3.9 mEq/dl     HCT=49.7%     Plt=324*103 Tbo/ul      Neutr=74%      





 
 
 
 
After ten days administration of IV fluid, BUN and createnine gradually became normal (Cr=1.1 mg/dl, BUN=14mg/dl).
There was no macroscopic or microscopic gastrointestinal pathology in upper and lower endoscopy. We took biopsies even from ileum terminal.  
We suspected endocrine tumors and pancreatic disorders, so we requested abdominal and pelvic CT scan (IV and oral contrast) and hormonal tests such as serum cortisole, metanephrin, normetanephrine, which were all normal. We therefore did an octrotide scan which was again normal.
Because almost all organic etiologies of chronic diarrhea were excluded, we focused on neurological and psychological causes of chronic diarrhea. Therefore we consulted with neurologist & psychiatrist and they recommended brain CT scan and EEG which were normal. After complete interview, the psychiatrist diagnosed PTSD and depressive disorder NOS and prescribed imipramin 25mg/day. After 10 days the chronic diarrhea improved. 
As we excluded all the organic causes, we concluded likely the patient had IBS with PTSD and depressive disorder NOS.
 

1. Talley NJ. Functional gastrointestinal disorders:Irritable bowel syndrome, Non ulcerdyspepsia, and non cardiac chest
pain.In:Goldman L. AusielloD.Cecil Text book of medicine.22 ed.Philadelphia:SANDERS;2004p.807-812.
2. Willams J, Snap Jr. Irratable bowel syndrome. In :Haubrich, schaffer B. Bockusgastroentrolog. Saunders;
1995.p.1619-1636.
3. Leigh H. Depression, mania and mood syndromes. In: Leigh H, Streltzer J.editors. Handbook of consultation-liaison
psychiatry.Springer; 2008.p. 100.
4. Creed F. Psychosomatic medicine: Gastrointestinal Disorders. In: Sadock BJ, Sadock VA, Ruiz P.editors. Kaplan
&Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009.p.
2268-2272.
5. SimeonD, Loewenstein RJ. Dissociative Disorders. In: Sadock BJ, Sadock VA, Ruiz P.editors. Kaplan &Sadock's
Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009.p. 1967.
6. Leigh H. Anxiety and anxiety syndromes. In: Leigh H, Streltzer J. editors. Handbook of consultation-liaison
psychiatry. Springer; 2008.p. 94.
7. DimsdaleJE, Irwin MR, Keefe FJ, Stein MB. Psychosomatic medicine: Stress and Psychiatry. In: Sadock BJ, Sadock
VA, Ruiz P. editors. Kaplan &Sadock's Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia: Lippincott
Williams and Wilkins; 2009.p. 2411.
8. Owyang C. Irritable bowel syndrome. In:Anthony S.Fauci.editors. Harrison’s principles of internal medicine.17th ed.
New York: McGraw Hill; 2008.p.1899-1903.
9. Talley NJ. Irritable bowel syndrome. In: Feldman M, Lawrence SF, Lawrence J.editors. Sleisenger and Fordtran’s
Gastrointestinal and liver disease. 9th ed. Canada: Saunders Elsevier; 2010.p.2091-2104.
10. Powell DW. Approach to the patient with diarrhea. In: Yamada T. Atlas of gastroenterology. 4th ed. Singapore:
Wiley-black well; 2009.p.34-35.
11. Camilleri M, Murray JA. Diarrehea and constipation. In:Anthony S. Fauci. editors. Harrison’s principles of internal
medicine.17th ed. New York: McGraw Hill; 2008.p.245-255.
12. Vahedi H, Ansari R, Jafari E. Irritable bowel syndrome. Middle east 2010; 2:66-77.