Hue University of Medicine and Pharmacy

Case 1. Abdominal pain, jaundice

Author: Le Minh Tan

You are a doctor who received a patient at Dept. Internal medicine with the following characteristics: Male, 55 years old, farmer, hospitalized for upper right abdominal pain and jaundice. These symptoms have appear about 10 days, initially with anorexia, fatigue, muscle aches in the arms and legs, fever accompanied by chills. After one week of extra abdominal pain, especially in the epigastrium and lower right side, there is no pain relief. Enlarged abdominal pain is yellow eyes, dark urine, and jaundice. The patient also has difficulty breathing and diarrhea for 2 days. No history of weight loss, diabetes, hypertension, vomiting, black stool or TB, no previous hepatitis B or hepatitis A vaccination, no history of medication special; However, patients often go to the doctor near the house to be injected and given medicine when tired, fever. Drinking alcohol 40g per day for 10 years, smoking 10 cigarettes per day. One month ago, between two crops, patients went to Laos to work in an area adjacent to the border.

Recorded at the hospital:

  • Consciousness, blood pressure 100 / 70mmHg, Circulation 106 times/min, breathing breath 22 times / min, T 38.50C
  • Fatigue, loss of appetite, muscle aches, skin pinching, yellowing of the eyes and jaundice, no palmetto, no nodules.
  • Good airway ventilation, no sound pathology.
  • Pain in the epigastrium and right lower abdomen, soft abdomen, pressure in the lower right flank, liver flanks in the ribs.


  • Blood cell count: WBCs 8.2x109 / l, Neu 70%; RBCs 3.51x1012 / l, Hb 11.2 g / l; Platelet 86x109 / L
  • Bilirubin (TT) 125.4 mmol / l, Bilirubin (D) 85.1 mmol / L, Bilirubin (I) 40.3 mmol / L
  • ALP 142 U / L AST 159 U / L ALT 197 U / l INR 1.6
  • Ure 14.2 mmol / l creatinine 135 μmol / l
  • Negligible Na + 140 mmol / l K + 3.9 mmol / l
  • Urine HC (-), Protein (-)
  • X-ray of the lungs and normal ECG.
  • Abdominal ultrasound: thick gallbladder but no gravel. OMC diameter # 8mm, no stones, normal liver structure, not large, no fluid in the abdomen.

What to do in this situation:

  • A. Ciprofloxacin antibiotics, intravenous metronidazole
  • B. Symptomatic treatment, HBsAg test, anti HCV, anti HAV
  • C. Doxycycline treatment
  • D. Blood smears for malaria parasites.

Case 2. Headache – subarachnoid hemorrhage

Author: Tran Thi Phuoc Yen

At the hospital emergency room medical facility

N.V.A, a 56-year-old patient, went to the emergency room for a sudden headache this morning after exercising. He said that this is the most intense headache he has ever had. At present, the pain is reduced, because he had to take a painkiller, but not significantly reduced and still very painful. In addition, the patient has no other expression, no vomiting, no blurring, no double vision, no weakness.

Recorded history:

  • Patient with a history of migraine from age 40, about 50% of cases have a history of symptoms with blurred vision, numbness of the left side. The first time the pain occurs with a frequency of about 4-5 times a month, in times when the patient can not do anything. However, in recent times, the frequency of attacks has decreased, with 4-5 months after the onset of a seizure, and responds very quickly to conventional analgesia.
  • In addition, patients with a history of hypertension for 10 years, regular treatment with Amlodipine 5mg / day.
  • In the mother family also Migraine.

Physical examination:

  • The patient is awake.
  • Circulation: 86 times / min
  • Blood pressure: 200/100 mmHg
  • T: 37.2 ° C
  • Headache, more on the left side, with no nausea or vomiting.
  • Normal quadriplegia, normal tendon reflex, Babinski (-)
  • No sign of stiff neck.
  • No sensory disorder
  • No cranial nerve paralysis
  • Regular heartbeat sound; normal lung.
  • Clinical evidence of any other abnormalities.

What you will do?

  • A1. Allow patient go home, prescribe analgesic treatment in the direction of Migraine with Sumatriptan. Appointment for a follow-up visit after 3 days.
  • A2. Give Advil Pain Relief (Acetaminophen + Ibuprofen), lower blood pressure with Nifedipine 10mg under the tongue and follow up in the emergency room.
  • A3 Hypotension and immediate referral to specialist hospital.

Case 3. Acute appendicitis

Author: Phan Dinh Tuan Dung

You are a surgeon who has just graduated for 2 years - you are participating in the department of specialty gastroenterology at your hospital today.

Clinical case:

Bao Chau, 21 years old, was taken to a multidisciplinary medical clinic for mild abdominal pain. In the emergency room, medical staff received a brief medical history and received a rapid cardiovascular examination 100 times per minute, with a fever of 37.8 °C. Exploitation of the pathological process by asking the patient and family member (patient's mother) indicates that the patient has had abdominal pain two days before admission. Patients with abdominal pain sometimes have periods near the menstrual cycle, however, this cycle is expected to last about 3 days. An abdominal clinical examination records patients with mild abdominal pain, mild but soft abdomen, only slightly painful abdominal area to the right. The emergency room physician recommends that an emergency doctor is consulted and that you go to the emergency room for an on-call consultation.

After the clinical examination, you agree with the records of the emergency room medical staff, but you also note that the patient looks more alarmed and anxious and asks for a doctor's referral. Ask your doctor about the clinical symptoms of a patient who is primarily involved in obstetrics.

The emergency room physician contacted the referral physician but was advised to refer to an oncologist for emergency surgery for a patient with a diagnosis of ectopic pregnancy. New arrivals can come to the same meeting.

You recommend a patient's abdominal ultrasound and continue to see another patient. After 30 minutes you get back and get the following ultrasound results: the esophageal swelling as well as the fluid in the pelvis and the pocket with Douglas, the size 1x2cm in the right ovary, not the bowel superfluous

What are your appointments?

  1. Do not handle anything, return home and return home after 01 week.
  2. Proposals for further follow-up in the emergency room
  3. Please wait for the doctor to diagnose and then make a decision
  4. Go for antibiotics, intravenous fluids right away then continue to monitor.

Case 4. Gastrointestinal perforation

Author: Nguyen Doan Van Phu

A 50-year-old male patient was admitted to the emergency department at 9:00 pm due to abdominal pain on day 3. Patients with abdominal pain, dull continuous pain, occasional cramps, nausea with nausea during the day, vomit and diluted white water, the patient was not able to defecate more than a day. Patient fatigue many recorded at the hospital: Circulation: 100 times / min, blood pressure: 95/65 mmHg, heat: 38.5 degrees. Your records at the emergency department: Medium to the moderate abdomen, palpable abdominal pain, decreased intestinal perforation, rectal bleeding without blood. The emergency department doctors do some tests: ctm, crp, unvaccinated film, abdominal ultrasound

Test results:

  • RBCs: 4.8x1012 / l    Hb: 135g / l   WBCs: 22x109 / 1    N: 90%        CRP: 120
  • Unvarnished ventricular: large intussusceptions, vapors, and vapor levels.
  • Abdominal ultrasound: a small volume of the abdomen, obstructive loops, difficult to survey the remaining organs.

Your decision?

  1. Place the stomach sone, pump the anal flux for the patient
  2. Antibiotics, pain relief for patients
  3. Invitation for doctors from the external department

Case 5. Postpartum hemorrhage

Author: Nguyen Hoang Long

In the hospital bedroom.

You are a 1 year obstetric residency in the hospital delivery room. Today is a very active session many serious illnesses need to track and many pregnant women on birth. At 3 o'clock, you are tired and just have a nap, the midwife tells you that there is a case of women in the hospital.

You meet the woman and explore the information of pregnant women as follows:

  • The 41-year-old woman, third trimester PARA (2002) 38 weeks, admitted to hospital for bipolar disorder.
  • Twice before birth usually at the clinic near the house. The first birth 10 years ago, birth 01 baby girl weighs 3700 grams, the second birth 6 years ago, usually 01 baby girl weighs 3800 grams, however this time pregnant women stay longer because the birth has missed and need to cure the uterus. These two children are attending elementary school and are very good at learning.
  • Personal history and family do not suffer from special diseases.
  • Pregnant women and their parents want to have more children, although when they do not use contraceptives, they are still not pregnant for nearly two years. Pregnant women decided to visit the reproductive-assisted center and performed in vitro fertilization. The procedure took place smoothly, about two months later, pregnant women to test and find themselves carrying twins. The ultrasonologist at the time of the first trimester reported to the women that they were twins and two amniocentes. Pregnant women are advised very carefully as well as have experienced two previous pregnancies, so the supply of nutrients, vitamins, iron, folic acid were taken two months ago.
  • At 13 weeks gestation, women were screened for Q1 and combined, resulting in a low risk of recurrence and subsequent follow-up.
  • Up to 20 weeks, the woman will be examined and screened for the second trimester. The doctor concludes that the two pregnancies are developing normally, however, the length of the cervix is ​​only 25 mm and is recommended for progesterone use. Naturally 1 capsule for up to 34 weeks.
  • However, up to 32 weeks, the woman was admitted to the hospital for pelvic pain, and the woman was admitted to the hospital because her doctor found that her uterus was fine. Pregnant women were treated for 5 days with Nifedipine 20 mg and Lung maturation with Dexamethasone. After 5 days of treatment, stable maternal condition, no cervical uterus, should be discharged.
  • Until now, pregnant women should go to hospital.

Current examination:

Circulation: 90 times / min. Temperature: 37 oC. Blood pressure: 130 / 90mmHg. Breathing frequency: 20 breaths / min.

Patients are well alert, have good contact, mucocutaneous pinky, no abnormalities, no abnormal lymph nodes. Other organs have not detected any abnormalities.

Physical examination:

  • Two well-proportioned breasts, dark isola, large nipple, no abnormal fluid flow
  • Uterine abdomen / waist circumference: 35/101 cm
  • Feet 1 is the head, hear the heart fetal heart rate of 150 times per minute.
  • The second you do not touch, can not find the fetal heart.
  • Cervical soft, erased almost all, open 3 cm, swelling, touching the fetus, normal pelvis.
  • You specify basic tests: blood count, blood type, coagulation, pregnancy ultrasound, and fetal heart rate.
  • Then you ask the midwife to give the baby the test and return to the room. You see the family members are very anxious.

After 30 minutes, the midwife informs you that the test results are as follows:

Coagulation test:

  • Normal platelet concentration
  • Full blood clotting
  • Bleeding time 3 minutes (1 - 4)
  • Blood clotting time 8 minutes (5 - 10)
  • Normal blood coagulation function

The blood formula:

  • White blood cells: 8.3 G / l
  • Hemoglobin: 3.35 T / l
  • HGB: 109 g / l
  • Hct: 31.3%
  • Platelets 115 G / l

Emergency ultrasound:

  • Gestational pregnancy in the womb
  • Pregnancy position 01: Left. Top hit. Pregnancy weight 2900 grams. Pregnancy: 148 / min. The largest amniocentesis is 5 cm. Grabbing behind the group 2. Maturity of each other: degree III
  • Position of pregnancy 02: Right. Top hit. Pregnancy weight 2800 grams. Pregnancy: 145 beats per minute. The largest amniocentesis is 4 cm. Grab the back of group 1.
  • Amniocentesis two.


  • Basic fetal heart rate: 160 beats per minute (drive 1), 150 beats per minute (drive 2)
  • Internal oscillation: 10 - 15 beats / minute
  • Increment: +
  • Reduction of DIP 1 in the fetal heartbeat 1.
  • Uterine contractions: 3 bouts / 10 minutes

You check the cervix open at this time, you press the amniotic fluid and give birth often because you think this case is quite favorable. Pregnant women and their families want to have a cesarean section for safety, but you explain to pregnant women and their families that they should give birth because they are doing well, they agree, but feel uncomfortable.

The first baby boy weighs 2700 grams, the Apgar 8/1 - 9/5 and the second baby boy weighs 2700 grams, the Apgar 8/1 - 9/5. You inform the pregnant woman and her family, they are very happy to hold the two grandsons as expected.

You pass the next steps to 6th year students are practicing in the obstetric department. You get a check-up for serious illnesses and other cases of labor.

15 minutes later, the midwife informs you that the current pregnant woman is still stable but the placenta is not clotting.

What do you do next?

  1. Ask 6th year students to pull the umbilical cord
  2. Continue to monitor the disease and will return after 15 minutes
  3. Return immediately

Case 6. Pre-eclampsia

Author: Nguyen Hoang Long

In the delivery room

You are a first year obstetrician and gynecologist. Today is your session at the hospital. Your attendance consists of 03 people: 01 primary doctor, 01 second year obstetric residency and you. The weather in recent days has been erratic, turning to cold air and heavy rain.

Your team is handing over 04 cases are tracking, and in the delivery room are 5 cases to monitor of birth. It's 2 am now, you feel quite tired. A 30-year-old woman is hospitalized for headaches.

Pregnant women were shown to have a third pregnancy (1011), a history of caesarean section three years ago due to the low birth weight, low birth weight. One miscarriage two years. Internal history of the disease has no special disease. Pregnant women do not remember definitively the last menstrual period, the first ultrasound in the first trimester of pregnancy has a date of birth, up to now is 34 weeks 3 days.

Recorded at the hospital:

  • The apple appetite, good contact. Pink mucosa skin. There are mild swelling of the legs, white, soft, pressed concave.
  • Circulation: 90 times / min. Temperature: 37 oC. Blood pressure: 140/100 mmHg. Breathing frequency: 16 bpm
  • Little headache. The heartbeat is clear, not heard. Two fields heard clearly, not heard rale.
  • Fundal height/abdominal girth measurements: 28/96 cm. 2 pregnant palpable.
  • Fetus number 1 positioned head-down, fetal heart rate 150 times / min. Fetus number 2 positioned inverted, fetal heart rate 140 times / minute. Do not feel uterus when touched. Soft abdomen, pain in the shade. Scar on the skin 10 cm, on the guard 2 cm, pressing painless. The vagina does not bleed.
  • Vaginal Exam: Cervix is long, closed, no abnormal fluid from the cervix. Tentacles are lumpy. Diameter 12 cm.

What do you do next?

  1. Give antihypertensive drugs + routine testing
  2. Test for pre-eclampsia
  3. Explain to pregnant women that this is a common symptom of pregnancy, not risky and rest for a time will lose all symptoms