a***u
发帖数: 318 | 1 小妹正在攻读NP，前不久完成导师给的case study，等批下来发现分数不理想，原因似
乎是我理解错误（因果不分），读了导师给我的“完美答案”，我心里依然固执地认为
我没错。知道这里的高手如云，所以想来讨个公道，当然输也要输的心服口服。
CASE STUDY
A young woman was admitted with 28 weeks of intermittent abdominal pain and
leg spasms. She had also noted increasing left leg pain for a few weeks
before admission. The leg pain had in-creased resulted in 14 days bedrest
before admission. The leg spasms were related to the movement of the lower
extremities. Review of systems was remarkable for in-creased irritability,
labile mood, and scalp pruritus. Her past medical history was significant
for Crohn disease, with multiple bowel resections secondary to obstruction
and adhesions. Her last surgery was 3 years earlier and involved the
resection of 120 cm of ileum. Since that time, her weight decreased from 160
pounds to 128 pounds. On presentation, the patient’s medications included
a multivitamin, calcium 500 mg/day, ibuprofen, fluoxetine, and a fentanyl
patch. The remainder of her history, including other surgical, social, and
family history, was unrevealing.
On physical examination, she was afebrile, with a pulse of 99 beats per
minute, respiratory rate of 22 per minute, and blood pressure 140/69 mm Hg.
Head and neck examination showed conjunctival pallor and excoriations on the
scalp. Her pulmonary and cardiac examinations were normal. Abdomin-al
examination revealed normal bowel sounds without tenderness or organomegaly.
Neurologic exami-nation was nonfocal. Musculoskeletal examination was
significant for tenderness over the ribs bilate-rally and severe pain on
movement of the right hip with markedly decreased range of motion.
Initial laboratory studies revealed serum calcium of 5.1 mg/dL, phosphorus
of 2.3 mg/dL, magne-sium of 1.5 mg/dL, and creatinine of 0.5 mg/dL. Her
albumin was 3.7 g/dL, and alkaline phosphatase was 498 U/L. Transaminases,
bilirubin, amylase, and lipase were all normal. Her hemoglobin was 10.3 g/dL
with a mean corpuscular volume of 110 fL.
1.What is the most likely cause for this patient's hypocalcemia? Explain
your answer.
她给我的答案是：
osteomalacia. 同时给我另外个同学的答案:
The most likely cause of this patient’s hypocalcemia是因为osteomalacia, 她
的临床表现 diffuse skeletal pain, muscle aches, and spasms, 和 alkaline
phosphatase升高 , hypophosphatemia (2.3 mg/dL),和 hypocalcemia (5.1 mg/dL),
which are definitive markers for osteomalacia.除了osteomalacia,
malabsorption syndrome must be considered, secondary to the removal of a
large portion of her ileum ( > 100 cm),导致胆盐吸收障碍引起的包括vit D在内的
脂溶性维生素缺乏。
而我认为，hypocalcemia is caused by short bowel syndrome due to ileum
resection.
Osteomalacia 是由上述病因导致的，是结果而不是hypocalcemia的原因。
拿到分数，我难过得一晚没睡。
由于某些原因，我在文中中英文穿插，望见谅！
版主如觉得此贴不合适，请删除。 | s********o
发帖数: 3319 | 2 我觉得你的答案不对。整个小肠都能吸收钙，你手术切掉一两段不会对钙吸收有直接影
响。
但是如果你碰巧切掉的是末端回肠，它影响到维生素D的吸收，没了维生素D，所有的小
肠上皮细胞就都不表达帮助钙吸收的钙结合蛋白，也就相当于整个小肠都废了，这个对
钙吸收的影响是非常非常非常大的。所以你的老师的答案是对的。
我个人的理解。
and
【在 a***u 的大作中提到】
: 小妹正在攻读NP，前不久完成导师给的case study，等批下来发现分数不理想，原因似
: 乎是我理解错误（因果不分），读了导师给我的“完美答案”，我心里依然固执地认为
: 我没错。知道这里的高手如云，所以想来讨个公道，当然输也要输的心服口服。
: CASE STUDY
: A young woman was admitted with 28 weeks of intermittent abdominal pain and
: leg spasms. She had also noted increasing left leg pain for a few weeks
: before admission. The leg pain had in-creased resulted in 14 days bedrest
: before admission. The leg spasms were related to the movement of the lower
: extremities. Review of systems was remarkable for in-creased irritability,
: labile mood, and scalp pruritus. Her past medical history was significant
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