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A 58-year-old man presents to the emergency department with severe crushing retrosternal chest pain radiating to his left jaw that began 90 minutes ago. An electrocardiogram (ECG) reveals 3 mm ST-segment elevation in leads V1 through V4. What is the most immediate and decisive reperfusion strategy recommended if primary percutaneous coronary intervention (PCI) cannot be performed within 120 minutes of first medical contact?

Pathologie Medicale

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A 65-year-old woman with a history of chronic heart failure with reduced ejection fraction (HFrEF, LVEF 30%) remains symptomatic (NYHA Class II) despite optimized doses of an ACE inhibitor, a beta-blocker, and a mineralocorticoid receptor antagonist. According to contemporary heart failure guidelines, which therapeutic modification provides a proven reduction in cardiovascular death and heart failure hospitalization?

Pathologie Medicale

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A 42-year-old male with a history of bicuspid aortic valve presents with a 3-week history of remittent fever, malaise, night sweats, and a new diastolic murmur at the right upper sternal border. Blood cultures grow Streptococcus gallolyticus (formerly S. bovis). In addition to targeted antibiotic therapy, what diagnostic screening procedure is mandatory?

Pathologie Medicale

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A 32-year-old woman with known severe persistent asthma presents with acute breathlessness, wheezing, and inability to complete full sentences. On physical examination, her respiratory rate is 32/min, pulse 124 bpm, oxygen saturation 91% on ambient air, and peak expiratory flow (PEF) is 45% of predicted. Which initial pharmacological intervention is most critical?

Pathologie Medicale

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A 54-year-old man who underwent total hip arthroplasty 10 days ago presents with sudden-onset pleuritic chest pain, dyspnea, and hemoptysis. His blood pressure is 85/50 mmHg, heart rate is 118 bpm, and arterial blood gas demonstrates hypoxemia and respiratory alkalosis. A computed tomography pulmonary angiography (CTPA) confirms saddle pulmonary embolism. What is the most appropriate definitive initial management?

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A 68-year-old heavy smoker with a 15-year history of chronic obstructive pulmonary disease (COPD) presents with increased sputum volume, increased purulence, and worsening breathlessness (Anthonisen Type 1 exacerbation). Arterial blood gas on room air shows pH 7.33, PaCO2 56 mmHg, PaO2 54 mmHg, and HCO3- 29 mmol/L. In addition to controlled oxygen therapy and bronchodilators, which intervention is indicated?

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A 52-year-old man with decompensated alcoholic cirrhosis presents with fever (38.6°C), generalized abdominal tenderness, and increasing confusion. Diagnostic paracentesis is performed. What finding in the ascitic fluid analysis confirms the diagnosis of spontaneous bacterial peritonitis (SBP)?

Pathologie Medicale

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A 48-year-old male with known cirrhosis presents with massive hematemesis and melena. Blood pressure is 80/50 mmHg, pulse 122 bpm. Along with restrictive blood transfusion (target hemoglobin 7-8 g/dL) and airway protection, which pharmacotherapy must be initiated immediately before emergency endoscopy?

Pathologie Medicale

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A 28-year-old man presents with bloody diarrhea (6-8 bowel movements per day), abdominal cramping, and low-grade fever for 4 weeks. Flexible sigmoidoscopy shows continuous, diffuse erythema, friability, and superficial ulcerations extending from the anal verge proximally through the sigmoid colon. Biopsies confirm crypt architectural distortion and crypt abscesses limited to the mucosa. What is the most likely diagnosis?

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A 60-year-old female presents with bilateral leg edema, periorbital puffiness, and foamy urine. Laboratory investigations reveal serum albumin 21 g/L, 24-hour urine protein 6.8 g, serum total cholesterol 340 mg/dL, and normal serum creatinine. Renal biopsy with immunofluorescence shows granular subepithelial deposits of IgG and C3 along the capillary loops, with diffuse thickening of the glomerular basement membrane on light microscopy. What is the most likely diagnosis?

Pathologie Medicale

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A 45-year-old man with chronic kidney disease presents with severe generalized muscle weakness. An urgent ECG demonstrates tall, peaked, narrow T waves with a shortened QT interval in precordial leads. Serum potassium is 7.2 mmol/L. What is the immediate first-line pharmacological agent required to protect the myocardium against malignant arrhythmias?

Pathologie Medicale

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A 72-year-old man presents with sudden right-sided hemiparesis and motor aphasia that started 75 minutes ago. Blood pressure is 165/95 mmHg, and capillary blood glucose is 120 mg/dL. An immediate emergency non-contrast brain CT scan rules out intracranial hemorrhage and shows an ASPECTS score of 10. There are no contraindications. What is the most appropriate next step in acute stroke management?

Pathologie Medicale

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A 24-year-old university student is admitted with high fever, severe headache, photophobia, and neck stiffness for 18 hours. Physical examination shows positive Kernig and Brudzinski signs, but no focal neurological deficits and no papilledema. Lumbar puncture yields cloudy cerebrospinal fluid (CSF) with 2,400 leukocytes/mm3 (88% neutrophils), protein 3.2 g/L, and CSF-to-serum glucose ratio of 0.18. Which empirical antimicrobial regimen is indicated?

Pathologie Medicale

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A 35-year-old female presents with nervousness, heat intolerance, palpitation, weight loss despite increased appetite, and bilateral exophthalmos. Examination reveals a diffuse, painless, non-nodular goiter with a vascular thrill and audible bruit. Thyroid function tests show TSH < 0.01 mIU/L and free T4 48 pmol/L (normal: 10-25). Which laboratory marker confirms the autoimmune etiology of Graves' disease (maladie de Basedow)?

Pathologie Medicale

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A 19-year-old male with type 1 diabetes is brought to the emergency department with nausea, vomiting, abdominal pain, and Kussmaul respirations. Laboratory evaluation reveals capillary blood glucose 420 mg/dL, arterial blood gas pH 7.18, serum bicarbonate 11 mmol/L, anion gap 24 mEq/L, and heavy urine ketones. What is the fundamental sequence of initial resuscitation for diabetic ketoacidosis (DKA)?

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A 44-year-old woman presents with progressive fatigue, generalized hyperpigmentation (most marked on the palmar creases and buccal mucosa), postural dizziness, and weight loss. Blood pressure is 88/56 mmHg supine and 72/44 mmHg standing. Laboratory findings show serum sodium 128 mmol/L, potassium 5.6 mmol/L, and fasting blood glucose 62 mg/dL. Which test is the standard confirmatory assessment for primary adrenal insufficiency (Addison's disease)?

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Which conventional six-month first-line regimen is used for a newly diagnosed adult with drug-susceptible pulmonary tuberculosis when a shorter eligible regimen is not selected?

Pathologie Medicale

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A 12-year-old child presents with migratory polyarthritis of the large joints, fever, and a new apical holosystolic murmur of mitral regurgitation following an untreated sore throat 3 weeks ago. Elevated antistreptolysin O (ASLO) titers and high C-reactive protein are noted. In addition to anti-inflammatory therapy and penicillin eradication, what is the secondary prophylaxis protocol recommended to prevent recurrent acute rheumatic fever (rhumatisme articulaire aigu — RAA)?

Pathologie Medicale

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A 22-year-old female presents with fatigue, cold intolerance, and pallor. Complete blood count reveals hemoglobin 8.4 g/dL, mean corpuscular volume (MCV) 68 fL (normal: 80-100), MCH 21 pg, and ferritin 6 ng/mL (normal: 15-150). What is the underlying pathophysiological mechanism of her anemia?

Pathologie Medicale

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A 62-year-old man presents with bone pain, pathological rib fractures, recurrent pneumonia, and fatigue. Serum protein electrophoresis demonstrates a prominent monoclonal spike (M-protein) in the gamma globulin region. Serum creatinine is 2.3 mg/dL, and serum corrected calcium is 11.8 mg/dL. Bone marrow biopsy reveals 45% clonal plasma cells. What is the diagnosis?

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A 30-year-old woman presents with symmetrical polyarthritis involving the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of both hands, lasting 4 months, with morning stiffness exceeding 1 hour. Serology shows highly positive anti-cyclic citrullinated peptide (anti-CCP) antibodies and elevated rheumatoid factor (RF). What is the first-line disease-modifying antirheumatic drug (DMARD) of choice?

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A 26-year-old woman presents with photosensitive facial butterfly rash, non-scarring alopecia, pleuritic chest pain, and polyarthralgia. Urine analysis demonstrates 2+ proteinuria and granular casts. Serology reveals antinuclear antibodies (ANA) 1:1280 (homogeneous pattern) and positive anti-double-stranded DNA (anti-dsDNA) antibodies with low serum C3 and C4 complement levels. What is the diagnosis?

Pathologie Medicale

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A 4-day-old full-term neonate develops jaundice. Physical examination reveals jaundice extending down to the abdomen and thighs, with normal active tone and vigorous feeding. The baby is exclusively breastfed. Blood group of the mother is O Rh-positive and the neonate is A Rh-positive. Total serum bilirubin is 16 mg/dL (predominantly unconjugated / indirect) and direct Coombs test is positive. What is the most likely diagnosis?

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A 10-month-old infant presents with high fever (39.5°C) that persists for 5 days, accompanied by bilateral non-purulent conjunctival injection, cracked red lips, a 'strawberry tongue', an erythematous polymorphous trunk rash, and indurated edema of the hands and feet. What is the primary therapy required to prevent coronary artery aneurysms?

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A 6-year-old child presents with sudden-onset periorbital and pretibial edema following an upper respiratory tract infection 10 days ago. Urinalysis shows 4+ protein and no hematuria. Serum albumin is 18 g/L and total cholesterol is 320 mg/dL. Renal function and complement C3 levels are normal. What is the recommended first-line therapy for this presumed idiopathic nephrotic syndrome (minimal change disease)?

Pathologie Medicale

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A 55-year-old male with a mechanical prosthetic aortic valve presents with fever, chills, and fatigue 6 months after surgery. Transthoracic echocardiogram shows a mobile vegetation on the prosthetic ring with mild paravalvular regurgitation. Blood cultures grow methicillin-resistant Staphylococcus epidermidis (MRSE). What is the recommended empirical antimicrobial regimen for prosthetic valve endocarditis?

Pathologie Medicale

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A 68-year-old man presents with fever, productive cough with rust-colored sputum, and right-sided pleuritic chest pain. Chest radiography reveals dense lobar consolidation with air bronchograms in the right lower lobe. His respiratory rate is 32 breaths/min, blood pressure is 88/54 mmHg, blood urea nitrogen is 28 mg/dL (urea > 7 mmol/L), and he is oriented in time and space (CURB-65 score = 3). What is the appropriate initial management setting and empirical antibiotic therapy?

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An asymptomatic 38-year-old healthcare worker undergoing routine occupational screening is found to have the following hepatitis B serology: HBsAg negative, anti-HBs positive (titre 180 mIU/mL), anti-HBc total negative. How should this serological profile be interpreted?

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A 4-year-old child presents with pallor, fatigue, generalized petechiae, fever, and diffuse bone pain. Complete blood count shows hemoglobin 7.1 g/dL, white blood cell count 68,000/mm3, and platelets 22,000/mm3. Peripheral blood smear and bone marrow aspiration demonstrate 85% lymphoblasts expressing CD19, CD10, and TdT, without cytoplasmic immunoglobulins. Which cytogenetic abnormality in B-cell acute lymphoblastic leukemia (B-ALL) confers an unfavorable prognosis requiring treatment intensification?

Pathologie Medicale

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A 25-year-old asymptomatic Mediterranean man undergoes routine premarital screening. Laboratory testing shows: RBC count 6.2 x 10^12/L, Hemoglobin 11.2 g/dL, MCV 64 fL, MCH 20 pg, and RDW 13% (normal: 11.5-14.5%). Serum ferritin is normal (120 ng/mL). The Mentzer index (MCV / RBC count in millions) is 10.3 (< 13). Hemoglobin electrophoresis demonstrates HbA 94.5%, HbA2 5.2% (elevated, normal: 2.0-3.3%), and HbF 0.3%. What is the definitive diagnosis?

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A 22-year-old man presents with right lower quadrant abdominal pain that started periumbilically 18 hours ago before migrating to the right iliac fossa. He has low-grade fever (38.1°C), anorexia, and nausea. On examination, localized tenderness and involuntary guarding are elicited at McBurney's point, and pain in the right iliac fossa is produced upon palpation of the left lower quadrant. What is the name of this specific clinical sign?

Pathologie Chirurgicale

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A 45-year-old multiparous woman presents with severe constant right upper quadrant pain radiating to the right scapula for 12 hours, accompanied by nausea, vomiting, and a temperature of 38.8°C. Abdominal ultrasound demonstrates a distended gallbladder with gallstones, gallbladder wall thickening of 5 mm with a double-contour appearance, pericholecystic fluid, and an ultrasound Murphy's sign. What is the preferred definitive surgical management for an operable patient?

Pathologie Chirurgicale

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A 50-year-old male with a history of alcohol abuse presents with severe epigastric pain radiating directly through to his back, accompanied by intractable vomiting. Serum lipase is 1,800 U/L (more than 10 times the upper limit of normal). Contrast-enhanced abdominal CT performed at 72 hours shows diffuse pancreatic enlargement with heterogeneous peripancreatic fluid collections and 40% non-enhancing pancreatic parenchymal necrosis. What is the primary initial medical resuscitation priority?

Pathologie Chirurgicale

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A 60-year-old female who had an open appendectomy 15 years ago presents with colicky abdominal pain, profuse bilious vomiting, absolute constipation for flatus and feces, and abdominal distension. Abdominal radiography demonstrates multiple dilated small bowel loops with central gas-fluid levels (air-fluid levels) that are wider than they are tall, and an absence of colonic gas. What is the most common etiology of this presentation?

Pathologie Chirurgicale

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A 74-year-old male with a longstanding reducible right groin swelling presents with 6 hours of agonizing right groin pain, vomiting, and inability to reduce the mass. On examination, there is a tense, exquisitely tender, non-pulsatile, non-reducible swelling located below and lateral to the pubic tubercle. The overlying skin is dusky red. What is the diagnosis and appropriate management?

Pathologie Chirurgicale

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A 40-year-old male with a history of untreated epigastric pain after meals presents with sudden, catastrophic, generalized abdominal pain that began 2 hours ago. He lies motionless, breathing shallowly. Examination reveals a rigid, board-like abdomen ('ventre de bois') with diffuse involuntary rebound tenderness. Upright chest radiography reveals crescentic subdiaphragmatic free air (pneumoperitoneum). What is the primary diagnosis?

Pathologie Chirurgicale

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In Morocco, hydatid disease (kyste hydatique du foie) caused by Echinococcus granulosus is an endemic zoonosis. A 35-year-old rural shepherd presents with right upper quadrant fullness. Abdominal ultrasound reveals a well-defined 8 cm unilocular spherical fluid collection in segment VII of the liver with a thickened wall and a detached undulating internal membrane ('water-lily sign' / signe du nénuphar). According to the Gharbi / WHO classification, what type of hydatid cyst is this?

Pathologie Chirurgicale

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A 66-year-old male presents with acute intestinal obstruction. Abdominal CT demonstrates an obstructing circular stenosing mass in the upper rectum / rectosigmoid junction with marked proximal colonic dilation (cecal diameter 10 cm) and no distant metastases. What is the classic emergency surgical procedure traditionally performed in an obstructed left-sided colon cancer when primary anastomosis is deemed high-risk?

Pathologie Chirurgicale

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A 73-year-old woman with chronic atrial fibrillation and poor medication compliance presents with sudden-onset, agonizing diffuse abdominal pain. On physical examination, her abdomen is soft, mildly tender, and non-distended, with no signs of peritoneal irritation. Her pain appears profoundly disproportionate to physical findings. Laboratory investigations reveal marked leukocytosis (22,000/mm3) and severe lactic acidosis (lactate 5.8 mmol/L). What is the most critical emergency diagnostic investigation of choice?

Pathologie Chirurgicale

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A 28-year-old motorcyclist is brought to the trauma bay following a high-speed collision. He complains of left upper quadrant pain and left shoulder pain (Kehr's sign). Blood pressure is 115/75 mmHg, heart rate is 88 bpm. Focused Assessment with Sonography for Trauma (FAST) reveals free fluid in the splenorenal recess. Abdominal contrast CT shows an 8 cm subcapsular splenic hematoma with a 4 cm parenchymal laceration (Grade III splenic injury) without active contrast extravasation ('blush'). The patient remains hemodynamically stable. What is the standard management strategy?

Pathologie Chirurgicale

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A 30-year-old male sustains a closed comminuted tibial shaft fracture treated with a plaster cast. Twelve hours later, he complains of severe, excruciating pain in the lower leg that is refractory to increasing doses of intravenous morphine. On examination, the anterolateral compartment of the leg is tense and woody. What is the earliest and most sensitive clinical finding of acute compartment syndrome (syndrome des loges)?

Pathologie Chirurgicale

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A 25-year-old construction worker sustains a high-energy crush injury to his left leg. Examination reveals an open tibial fracture with extensive periosteal stripping, exposed bone, severe contamination, and soft-tissue loss that prevents adequate bone coverage without a flap. Distal perfusion is intact. According to the Gustilo-Anderson classification, how is this injury classified?

Pathologie Chirurgicale

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An 82-year-old osteoporotic female falls at home and cannot bear weight on her right lower extremity. On physical examination, the right leg is shortened, abducted, and externally rotated. Radiographs demonstrate a displaced intracapsular femoral neck fracture (Garden Stage IV). What is the primary surgical treatment of choice in this active elderly patient to achieve early mobilization and avoid avascular necrosis of the femoral head?

Pathologie Chirurgicale

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In the Advanced Trauma Life Support (ATLS) protocol for the resuscitation of a severe polytrauma patient in hemorrhagic shock, which physiological triad ('triade létale') represents the self-reinforcing vicious cycle of mortality that dictates damage control surgery?

Pathologie Chirurgicale

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A 35-year-old male presents with acute, agonizing, spasmodic left flank pain radiating along the groin and into the ipsilateral hemiscrotum. He has microscopic hematuria on dipstick. Serum creatinine is 0.9 mg/dL. He is afebrile (36.8°C) and hemodynamically stable. What is the most effective first-line analgesic class recommended for uncomplicated acute renal colic (colique néphrétique aiguë)?

Pathologie Chirurgicale

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A 16-year-old adolescent boy wakes up from sleep with acute, excruciating left testicular pain and vomiting. Examination shows a swollen, tender, high-riding left testis with horizontal lie, and the ipsilateral cremasteric reflex is completely absent. Color Doppler ultrasound is requested, but the ultrasound technician will arrive in 90 minutes. What is the immediate correct management decision?

Pathologie Chirurgicale

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A 24-year-old man receives a blow to the temporal region during a soccer match, sustaining a brief loss of consciousness followed by complete lucidity. Three hours later, he becomes drowsy, complains of severe headache, and develops a dilated and sluggish right pupil with progressive left hemiparesis. Non-contrast cranial CT reveals a hyperdense, biconvex (lenticular) extra-axial collection beneath the right squamous temporal bone that does not cross cranial suture lines. What is the vascular source of this hemorrhage?

Pathologie Chirurgicale

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