Male patient, 69 years old, smoker (2 packs per day), comes to the Emergency Room around 2 p.m.

accusing violent pain in the epigastric area, started in the morning, with increasing intensity. The patient
tells you that he went to a party one night before, and drank 3 beers and a cup of wine; last meal at 12
p.m. the previous day. Also, he had some headaches a few days before, taking some anti-inflammatory
drugs. First investigations made in the ER are a ECG (normal), and a CBC showing a slighty elevated
WBC (10200/mm3).
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Describe the clinical examination of the patient.

Clinical suspicion (diagnosis).
Differential diagnosis.
Plan of investigations (biological and imagistic) to sustain your diagnosis.
Final diagnosis.
Plan of treatment (medical and surgical if needed).
Complications (pre- and postoperative). Explain why these complications may appear.

A 50-year-old man presents to the emergency department with vomiting and epigastric pain which
radiates through to the back. The pain was of gradual onset, coming on over the last 2 days. He denies any
previous episodes. He is not on any regular medication, but admits to drinking in excess of eight cans of
lager a day. He is a heavy smoker, but denies any recreational drug use. He is homeless and relates his
heavy drinking to depression. The patient is sweaty and agitated. He says he is unable to lie flat for the
examination and
vomits persistently. His blood pressure is 150/80 mmHg and he has a pulse rate of 120/min.
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Describe the clinical examination of the patient.

Clinical suspicion (diagnosis).
Differential diagnosis.
Plan of investigations (biological and imagistic) to sustain your diagnosis.
Final diagnosis.
Plan of treatment (medical and surgical if needed).
Complications (pre- and postoperative). Explain why these complications may appear.

A 41-year-old businessman presents to the emergency department with epigastric pain and vomiting. The
pain began suddenly 2 h previously, followed by 34 episodes of bilious vomiting. He had been
previously fit and well. He is a smoker and drinks 4060 units of alcohol per week. The patient is sweaty
and only comfortable while lying still. His blood pressure is 170/90 mmHg, pulse 110/min and
temperature 37.5C.
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Describe the clinical examination of the patient.

Clinical suspicion (diagnosis).
Differential diagnosis.
Plan of investigations (biological and imagistic) to sustain your diagnosis.
Final diagnosis.
Plan of treatment (medical and surgical if needed).
Complications (pre- and postoperative). Explain why these complications may appear.

A 50-year-old man is referred to the surgical outpatients with a 6-month history of epigastric pain, weight
loss and altered bowel habit. The epigastric pain is present throughout the day and is not relieved by food.
He has noticed that his bowels have been opening more frequently and that the stools are bulky, pale and
malodorous. His appetite has been poor over the last couple of months and he has lost 2 stone in weight.
His previous medical history includes treatment for alcohol dependence. He still drinks at least 10 units of
alcohol per day and is a heavy smoker.
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Describe the clinical examination of the patient.

Clinical suspicion (diagnosis).
Differential diagnosis.
Plan of investigations (biological and imagistic) to sustain your diagnosis.
Final diagnosis.
Plan of treatment (medical and surgical if needed).
Complications (pre- and postoperative). Explain why these complications may appear.

A 62-year-old man is attending your surgical care unit. The general practitioners (GP) letter states that he
has been suffering from epigastric pain for the last 6 months. The pain typically occurs about an hour
after eating and is associated with nausea and belching. He has had some relief from a proton pump
inhibitor, but the symptoms have not entirely settled, despite a 2-month course. Hb=11,3 g/dl,
WBC=7000/mm3, Platelets=192000/mm3.
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Describe the clinical examination of the patient.

Clinical suspicion (diagnosis).
Differential diagnosis.
Plan of investigations (biological and imagistic) to sustain your diagnosis.
Final diagnosis.
Plan of treatment (medical and surgical if needed).
Complications (pre- and postoperative). Explain why these complications may appear.

A 56 years old male patient presented to the general practitioner 2 months previously with epigastric
discomfort and bloating. He was prescribed a proton pump inhibitor which failed to improve his
symptoms. He has no history of gastro-oesophageal reflux or gallstones and is not on any other regular
medication. He smokes 20 cigarettes a day. The GP also sent some blood tests: Hb=9 g/dl, proteins=4,2
g/dl, WBC=8900/mm3. On general examination, you find a solid mass in the left supraclavicular fossa,
painless, cca. 2 cm diameter.
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Describe the clinical examination of the patient.

Clinical suspicion (diagnosis).
Differential diagnosis.
Plan of investigations (biological and imagistic) to sustain your diagnosis.
Final diagnosis.
Plan of treatment (medical and surgical if needed).
Complications (pre- and postoperative). Explain why these complications may appear.