Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 46-year-old woman presents to the emergency department with a 1-day history of constant right upper quadrant abdominal pain.

The pain began after eating fried pork. She describes the severity of the pain as a 7 out of 10. She reports that the pain also seems to radiate to her back near her right scapula. She feels nauseated and has vomited twice. She has had similar pain about once a month for the past month but of less severity. The pain comes on and worsens after eating food but previously it has resolved within an hour. She also reports of fever.

She does not have yellow discolouration of her eyes, has not lost weight, and does not have diarrhea, constipation, bleeding, or dark-colored stools. There is no history of abdominal distension or a mass in her abdomen.

She is Para 6 + 0. She has no significant medical or surgical history, is not on any medication, and has no allergies. She does not smoke, nor does she drink alcohol. Her diet is usually high in fat. Her review of symptoms is unremarkable.

She appears ill on physical exam. Her temperature is 37.7 C, heart rate is 110 beats per minute, and blood pressure is 120/80 mmHg. Her BMI is 33. There is no jaundice. She has marked tenderness to palpation in the epigastric region and right upper quadrant. When the right upper quadrant is palpated while she is taking a deep breath, she abruptly stops inspiration due to the pain. No masses are palpable. There is no rigidity, rebound tenderness, or guarding. The rest of her physical examination is unremarkable.

Her ultrasound shows stones in the gallbladder, gallbladder wall thickness of 6mm, and pericholecystic fluid. The diameter of the Common Bile Duct is 1.8 mm and there are no stones visualized within it. The liver parenchyma appears normal. Sonographic Murphy’s sign is positive. 

These are the results of her laboratory investigations:

WBC count 14 x 10 ^3 u/L (4.1 – 10.9 x 10^3 u/L), Total Bilirubin 1.0 mg/dL (0.1 – 1.2 mg/dL), Alkaline phosphatase 70 units/L (33-131 u/L), Amylase 60 units/L (30 – 100 u/L), Lipase 30 units/L (7 – 60 u/L)

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 23-year-old woman presents to the emergency department with a 12-hour history of right lower quadrant (RLQ) abdominal pain.

The pain originated in the umbilical region and radiated diffusely across the lower abdomen and is now localized in the right lower quadrant. It was of sudden onset, sharp, and constant with increasing intensity. Severity was rated 8 out of 10 on a scale of 1-10 with one being no pain and 10 being the most pain possible. She took over-the-counter Ibuprofen 400mg but this did not alleviate the pain. The pain was exacerbated by lifting the right leg.

She has vomited twice and reports that she has not eaten for 24 hours due to a lack of appetite. She opened her bowel post-onset of the pain with no change in the consistency of the stool, and no blood or mucus. She does not have abdominal swelling, dysuria, increased frequency of micturition, vaginal bleeding, or purulent vaginal discharge. She is nulliparous and her last menstrual period was 2 weeks ago with no complaints of dysmenorrhoea. She also has no history of unintentional weight loss, episodes of dyspepsia, strenuous physical activity or abdominal trauma.

There is no significant past medical and surgical history. Drug history includes the oral contraceptive pill. She has no known drug allergies. There is no relevant family history. She does not smoke nor does she use recreational drugs. She drinks alcohol occasionally.

On examination, she has a temperature of 38.5 degrees Celsius, absent bowel sounds, and marked tenderness to palpation at 1/3 the distance from the anterior superior iliac spine to the umbilicus. While palpating the left lower quadrant, she reports pain in the right lower quadrant. Active flexion and internal rotation of her right hip reproduces the pain. The skin on the RLQ is hypersensitive to touch. Gentle percussion over the right lower quadrant elicits rebound tenderness. There are no hernias. No abnormalities were detected on pelvic and digital rectal exam.

A complete blood count reveals leukocytosis of 13.5 x 10^3/uL with 15% bands. Urinalysis demonstrates 1+ WBCs without bacteria. The pregnancy test is negative.

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 29-year-old man presents with yellow discolouration of the eyes.

For the past week, he has felt unwell with decreased oral intake, a low-grade fever, which he recorded at about 37.7 C, fatigue, anorexia, nausea, and occasional vomiting. He noticed that his eyes became yellow about 4 days ago. Since that time, he has had continuous mild pain in his right upper abdomen. His urine has also gotten darker. There is no change in the colour of his stool.

He has no significant past medical history. However, he has been unable to donate blood within the past year for reasons he cannot recall. He has not travelled recently. He works as an accountant. His only medication is Ibuprofen.

For his social history, he currently uses marijuana and MDMA (Ecstasy) recreationally and has a prior history of Injection Drug Use (IDU) and cocaine. For his sexual history, he has had 5 sexual partners in the past 6 months. He does not consistently use condoms.

On physical exam, he appears ill and has obvious jaundice with scleral icterus. Temperature is 38.0 C, Blood Pressure 110/70 mmHg, Heart Rate 105 beats per minute, Respiratory Rate 16 breaths per minute, and Room air SpO2 of 99%. The lung and heart are normal apart from tachycardia.

The upper border of the liver is in the 6ICS MCL. Liver span is 15 cm in percussion and palpable 6 cm below the right costal margin. The liver edge is smooth and tender to palpation. The spleen edge is non-enlarged. There are no stigmata of peripheral liver disease and no peripheral oedema.

These are his lab results: AST 1234 U/L, ALT 1560 U/L, ALP 394 U/L, Total Bilirubin 13.4 mg/dL, Direct bilirubin 12.2 mg/dL, INR 2.3, aPTT 52 seconds.

These are the results of his hepatitis serology: IgM Anti-HAV Negative, IgG Anti-HAV Negative, IgM Anti-HBc Positive, IgG Anti-HBc Hep B Negative, HBsAg Positive, Anti-HBs Negative, HBeAg Positive, Anti-HBe Negative, Anti-HCV Positive.

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 45-year-old male motorcyclist is brought to the Emergency Department after hitting the rear-end of a car at highway speeds. He was wearing a helmet but was thrown from his motorcycle. He was found awake in the field by paramedics, but then quickly became unconscious. His airway is patent, but his respiration is shallow and irregular. His blood pressure is 150/90 mmHg, heart rate is 60 beats per minute, and respiratory rate is 20 breaths per minute. In response to the sternal rub, he moans and withdraws his right upper and lower extremities. He does not move his left upper or lower extremity, and he does not open his eyes. His right pupil is 6mm and non-reactive, while his left is 3mm and reactive to light. There is no obvious head injury or laceration. There is no discharge from the nose or the ears. However, there is a right hemotympanum. The oropharynx is clear. The rest of the physical exam is normal.

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 17-year-old girl with a history of Type I Diabetes Mellitus is brought to the Emergency Department with nausea, vomiting, lethargy, and dehydration. The mother reports that she stopped taking her insulin a day before the presentation. She is a thin woman in mild respiratory distress. Respiratory rate is 28 breaths per minute, Blood Pressure 80/40mmHg, Heart Rate 112 beats per minute, Temperature 37.2 C. There are normal heart sounds, the lungs are clear, the abdomen is soft, and there is no organomegaly. She is responsive and oriented to time, place, and person, but somnolent and weak. Mucous membranes are dry. These are her lab results: Serum sodium 126 (132 – 146) mEq/L, Potassium 4.3 (3.5 – 5.5) mEq/L, Magnesium 1.2 (1.3 – 2.1 ) mEq/L, BUN 76 (9-23 )mg/dl, Creatinine 2.2 (0.5 – 1.1) mg/dl, Bicarbonate 10 (22 – 25) mmol/L, Chloride 88 (99 – 109 ) mEq/L, Serum glucose 40 mmol/L (< 11 mmol/L)

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 25-year-old man weighing 70 kg is brought to the casualty department one hour after sustaining burn injuries to his face, torso, and upper extremities in a house fire. He is awake but appears confused and disoriented. He also complains of a severe headache. On examination, his temperature is 39.7 C, blood pressure 90/74 mmHg, heart rate 120 beats per minute, respiratory rate 26 breaths per minute, and oxygen saturation 89%. He has blistering, painful burns to the face with singed nasal hairs and carbonaceous sputum. The remainder of his skin that is not burned has a cherry-red appearance. The burns on his chest and back are painless, circumferential, white, dry, and leathery. The bilateral upper extremities are also burned with painful, swollen, mottled areas with blisters that appear to have open, weeping surfaces. He also has sunken eyes, a dry tongue, and a slow capillary refill.

Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 55-year-old post-menopausal woman presents with a new breast mass in her right breast. She states that the mass has been there for about 3 months and has slowly grown in size. She first noticed it when she was taking a shower. The mass is not painful. She reports no nipple discharge, no nipple inversion, and no skin changes. She had her first menstrual period at 11 years of age. Her only pregnancy was at 35 years of age. Her mother and sister both had breast cancer. You proceed to perform a physical examination, starting with an inspection of the breasts. On physical examination, she has a 2cm palpable, hard, ill-defined, immobile, non-tender mass in the upper outer quadrant of her right breast. There is no palpable axillary or supraclavicular lymphadenopathy.