Abdominal wall, peritoneum, esophagus and stomach.

Abdominal wall, peritoneum, esophagus and stomach.

Dr. James Cork, a 26 year old dentist, has been unwell for over 1 year. During this time he reports he has had diarrhea characterized by four to six loose, bulky stools per day without blood, mucus, or pus. He has been up at least once each night to move his bowels. James has lost 7 kg despite a very good appetite. He has not travelled outside of southern Ontario or been camping. His partner of 7 years, Richard, is in good health and has not suffered any of these symptoms, nor has James been in contact with anyone else with similar symptoms. His family physician found that his hemoglobin is low.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

Ted Mitchell is a 38 year old male who is homeless. He has been on and off the streets for the last 15 years. As a teenager, he started hanging out with "the wrong crowd" and his father, Dr. Ted Mitchell Sr. told him he could not return home till "you have cleaned up your act". Ted continues to abuse drugs, and any money he can get, has gone toward purchasing alcohol, his drug of choice.

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

Amanda, a 12 year old girl, has been accompanied by her mother to see her family doctor for a routine check-up. Her mother is a single mom who works shift work as an R.N. at the local E.R. department. She and Amanda currently reside in a suburban neighbourhood of Hamilton. Amanda attends a public school in her neighbourhood and complains of being constantly teased by her classmates for being "bigger". According to her mom, Amanda participates in gym class, but does not get much more physical activity than that. Amanda spends a lot of time alone while her mother works shifts. She admits to watching approximately 3 hours of television per day on weekdays and 5 hours on the weekends. She is also on the internet, chatting on MSN, for 1-2 hours per day. Her mother is also obese and is not worried about her daughter's current weight or the sedentary lifestyle and is rather pleased that Amanda is a "good girl". Amanda does not express interest in participating in local clubs or extracurricular activities and indicates that she is simply not an "athletic type" of individual.

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

John Franks is a 66-year-old male with a complicated course of Crohn’s disease over 30 years, requiring multiple surgical resections of his small bowel due to inflammation and obstruction. He has been treated with several immunosuppressive and biological treatments for his IBD, but has had a loss of response to these medications despite some temporary improvement in his disease activity. Despite currently being on ustekinumab (Stelara), John has had evidence of active disease and is currently on a tapering course of prednisone for a recent flare of his IBD. He was recently admitted to hospital with another partial small bowel obstruction and he is worried that he may need further surgery. "They’ve removed so much of my small intestine already that I am worried that I’m going to get short bowel syndrome." You discuss optimizing his dosages of his treatments in an attempt to induce remission of his disease, and to avoid the need for further surgery. He asks: "If I do have short bowel syndrome, what kind of special diet will I need to go on to maximize my nutrition?"

Learn how to perform the abdominal history and physical examination.

Learn how to perform the abdominal history and physical examination.

Lauren Bick is a 13-year-old girl who presents to her family physician's office with a 6-month history of weight loss. Her mother is concerned because she has noticed that Lauren has lost at least 10 pounds since her last doctor's visit which she had just before she started at her new school. Although Lauren has always been a "petite" girl, she is now the shortest in her class. The doctor asks Lauren's mom to give her a few minutes alone with Lauren. Once Lauren's mom has left the room, the doctor reviews the limits of confidentiality with Lauren and asks her about her weight loss. Lauren explains that she has met a new group of friends who do not believe that it is healthy to eat animals so she has joined them in following a vegan diet. She also reports that she's recently joined the long distance running club at her school. Lauren indicates that despite her mother's wishes, Lauren's goal is to get her weight down to 25 kg in the next few months. Lauren requests that you don't tell her mother this as it will likely cause them to argue. Lauren's menarche was at age 11 and she had been having regular menstrual periods but in the last 4 months, she has not had a period. Lauren indicates that she has not been sexually active. On questioning, she reports some constipation and says that she often feels cold.

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

Lauren Bick is a 13-year-old girl who presents to her family physician's office with a 6-month history of weight loss. Her mother is concerned because she has noticed that Lauren has lost at least 10 pounds since her last doctor's visit which she had just before she started at her new school. Although Lauren has always been a "petite" girl, she is now the shortest in her class. The doctor asks Lauren's mom to give her a few minutes alone with Lauren. Once Lauren's mom has left the room, the doctor reviews the limits of confidentiality with Lauren and asks her about her weight loss. Lauren explains that she has met a new group of friends who do not believe that it is healthy to eat animals so she has joined them in following a vegan diet. She also reports that she's recently joined the long distance running club at her school. Lauren indicates that despite her mother's wishes, Lauren's goal is to get her weight down to 25 kg in the next few months. Lauren requests that you don't tell her mother this as it will likely cause them to argue. Lauren's menarche was at age 11 and she had been having regular menstrual periods but in the last 4 months, she has not had a period. Lauren indicates that she has not been sexually active. On questioning, she reports some constipation and says that she often feels cold.

John Franks is a 66-year-old male with a complicated course of Crohn’s disease over 30 years, requiring multiple surgical resections of his small bowel due to inflammation and obstruction. He has been treated with several immunosuppressive and biological treatments for his IBD, but has had a loss of response to these medications despite some temporary improvement in his disease activity. Despite currently being on ustekinumab (Stelara), John has had evidence of active disease and is currently on a tapering course of prednisone for a recent flare of his IBD. He was recently admitted to hospital with another partial small bowel obstruction and he is worried that he may need further surgery. "They’ve removed so much of my small intestine already that I am worried that I’m going to get short bowel syndrome." You discuss optimizing his dosages of his treatments in an attempt to induce remission of his disease, and to avoid the need for further surgery. He asks: "If I do have short bowel syndrome, what kind of special diet will I need to go on to maximize my nutrition?"

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

Dr. James Cork, a 26 year old dentist, has been unwell for over 1 year. During this time he reports he has had diarrhea characterized by four to six loose, bulky stools per day without blood, mucus, or pus. He has been up at least once each night to move his bowels. James has lost 7 kg despite a very good appetite. He has not travelled outside of southern Ontario or been camping. His partner of 7 years, Richard, is in good health and has not suffered any of these symptoms, nor has James been in contact with anyone else with similar symptoms. His family physician found that his hemoglobin is low.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

Dr. James Cork, a 26 year old dentist, has been unwell for over 1 year. During this time he reports he has had diarrhea characterized by four to six loose, bulky stools per day without blood, mucus, or pus. He has been up at least once each night to move his bowels. James has lost 7 kg despite a very good appetite. He has not travelled outside of southern Ontario or been camping. His partner of 7 years, Richard, is in good health and has not suffered any of these symptoms, nor has James been in contact with anyone else with similar symptoms. His family physician found that his hemoglobin is low.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

Nick DeMarco is a 51 year old physical education teacher at a local elementary school. He has noticed increasing fatigue with exertion and complains about feeling exhausted at the end of the school day. He explains that he has been experiencing epigastric discomfort after eating and he has tried taking Advil for pain relief. He states the pain and regurgitation wakes him up at night. He reports that he is usually able to get back to sleep after taking antacids and a glass of milk.

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Nick DeMarco is a 51 year old physical education teacher at a local elementary school. He has noticed increasing fatigue with exertion and complains about feeling exhausted at the end of the school day. He explains that he has been experiencing epigastric discomfort after eating and he has tried taking Advil for pain relief. He states the pain and regurgitation wakes him up at night. He reports that he is usually able to get back to sleep after taking antacids and a glass of milk.

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Nick DeMarco is a 51 year old physical education teacher at a local elementary school. He has noticed increasing fatigue with exertion and complains about feeling exhausted at the end of the school day. He explains that he has been experiencing epigastric discomfort after eating and he has tried taking Advil for pain relief. He states the pain and regurgitation wakes him up at night. He reports that he is usually able to get back to sleep after taking antacids and a glass of milk.

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Nick DeMarco is a 51 year old physical education teacher at a local elementary school. He has noticed increasing fatigue with exertion and complains about feeling exhausted at the end of the school day. He explains that he has been experiencing epigastric discomfort after eating and he has tried taking Advil for pain relief. He states the pain and regurgitation wakes him up at night. He reports that he is usually able to get back to sleep after taking antacids and a glass of milk.

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Mr. Cheung presents to the emergency department with a 2 day history of worsening pain in the right upper quadrant of his abdomen. He had been in the ER last year with pain in his right flank, but while that pain was colicky in nature, he currently describes a more constant pain. The right flank pain a year ago was accompanied by hematuria and he ended up passing a kidney stone. Currently, he has felt nauseated but has not vomited and he has been anorexic for over 24 hours. He finally came to ER after developing some fevers and chills.

Ted Mitchell is a 38 year old male who is homeless. He has been on and off the streets for the last 15 years. As a teenager, he started hanging out with "the wrong crowd" and his father, Dr. Ted Mitchell Sr. told him he could not return home till "you have cleaned up your act". Ted continues to abuse drugs, and any money he can get, has gone toward purchasing alcohol, his drug of choice.

Mr. Cheung presents to the emergency department with a 2 day history of worsening pain in the right upper quadrant of his abdomen. He had been in the ER last year with pain in his right flank, but while that pain was colicky in nature, he currently describes a more constant pain. The right flank pain a year ago was accompanied by hematuria and he ended up passing a kidney stone. Currently, he has felt nauseated but has not vomited and he has been anorexic for over 24 hours. He finally came to ER after developing some fevers and chills.

Ted Mitchell is a 38 year old male who is homeless. He has been on and off the streets for the last 15 years. As a teenager, he started hanging out with "the wrong crowd" and his father, Dr. Ted Mitchell Sr. told him he could not return home till "you have cleaned up your act". Ted continues to abuse drugs, and any money he can get, has gone toward purchasing alcohol, his drug of choice.

Abdominal wall, peritoneum, esophagus and stomach.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Ted Mitchell is a 38 year old male who is homeless. He has been on and off the streets for the last 15 years. As a teenager, he started hanging out with "the wrong crowd" and his father, Dr. Ted Mitchell Sr. told him he could not return home till "you have cleaned up your act". Ted continues to abuse drugs, and any money he can get, has gone toward purchasing alcohol, his drug of choice.

Abdominal wall, peritoneum, esophagus and stomach.

Abdominal wall, peritoneum, esophagus and stomach.

Abdominal wall, peritoneum, esophagus and stomach.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

Abdominal wall, peritoneum, esophagus and stomach.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

Abdominal wall, peritoneum, esophagus and stomach.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Dr. James Cork, a 26 year old dentist, has been unwell for over 1 year. During this time he reports he has had diarrhea characterized by four to six loose, bulky stools per day without blood, mucus, or pus. He has been up at least once each night to move his bowels. James has lost 7 kg despite a very good appetite. He has not travelled outside of southern Ontario or been camping. His partner of 7 years, Richard, is in good health and has not suffered any of these symptoms, nor has James been in contact with anyone else with similar symptoms. His family physician found that his hemoglobin is low.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Large bowel, blood supply and lymph drainage of the GI system.

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Large bowel, blood supply and lymph drainage of the GI system.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Mike Bayuk, a 55 year old businessman, presents to the ER in Hagersville with severe abdominal pain. He indicates that the pain is located in the epigastric area and radiates into his back. He finds the pain is relieved when he sits up with his trunk flexed and his knees bent. He rates the pain as "11 out of 10".

Liver, gall bladder, biliary tree, pancreas and small intestine.

Ted Mitchell is a 38 year old male who is homeless. He has been on and off the streets for the last 15 years. As a teenager, he started hanging out with "the wrong crowd" and his father, Dr. Ted Mitchell Sr. told him he could not return home till "you have cleaned up your act". Ted continues to abuse drugs, and any money he can get, has gone toward purchasing alcohol, his drug of choice.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Mr. Cheung presents to the emergency department with a 2 day history of worsening pain in the right upper quadrant of his abdomen. He had been in the ER last year with pain in his right flank, but while that pain was colicky in nature, he currently describes a more constant pain. The right flank pain a year ago was accompanied by hematuria and he ended up passing a kidney stone. Currently, he has felt nauseated but has not vomited and he has been anorexic for over 24 hours. He finally came to ER after developing some fevers and chills.

Liver, gall bladder, biliary tree, pancreas and small intestine.

Mr. Cheung presents to the emergency department with a 2 day history of worsening pain in the right upper quadrant of his abdomen. He had been in the ER last year with pain in his right flank, but while that pain was colicky in nature, he currently describes a more constant pain. The right flank pain a year ago was accompanied by hematuria and he ended up passing a kidney stone. Currently, he has felt nauseated but has not vomited and he has been anorexic for over 24 hours. He finally came to ER after developing some fevers and chills.