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Clinical reasoning is a competence that the doctor develops and that is essential for his medical practice. Clinical reasoning includes aspects related to observation, critical thinking and communication skills with the patient, since it integrates the previous knowledge that the doctor has about a disease or medical problem with obtaining information from the clinical aspects that the patient provides. and with the mental process of processing the clinical information provided by the patient to the health professional during the interrogation or anamnesis, together with the interpretation of the findings in the physical examination and, where appropriate, of the complementary tests, allowing the elaboration of a set of diagnoses likely for efficient clinical decision making. The present work intends to address the subject in the simplest way possible so that the medical teacher takes it into account and facilitates its development in the doctor in training.

El razonamiento clínico es una competencia que el médico desarrolla y que es fundamental para su práctica médica. El razonamiento clínico incluye aspectos relacionados con la observación, el pensamiento crítico y las habilidades de comunicación con el paciente, ya que integra los conocimientos previos que el médico tiene sobre una enfermedad o problema médico mediante la obtención de información de los aspectos clínicos que el paciente proporciona y con el proceso mental de procesar la información clínica proporcionada por el paciente al profesional sanitario durante el interrogatorio o anamnesis, aunado a la interpretación de los hallazgos en la exploración física y, en su caso, de las pruebas complementarias, permite elaborar un conjunto de diagnósticos probables para la eficiente toma de decisiones clínicas. El presente trabajo tiene la intención de abordar el tema de la manera más sencilla posible para que el docente médico lo tome en cuenta y facilite su desarrollo en el médico en formación.

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BACKGROUND: Postoperative abdominal adhesions (PAAs) are present in more than 90% of patients undergoing abdominal surgery. They are a cause of chronic pain, hospitalizations, multiple surgeries, and infertility in women of reproductive age. The participation of three processes have been recognized: coagulation, fibrinolysis, and inflammation. The usefulness of subcutaneous enoxaparin in their prevention has been established. The objective is to establish the safest and most efficient dose for PAA prevention by testing five different doses of subcutaneous enoxaparin (0.25, 0.5, 1, 1.5, and 2 mg/kg/day) given in one dose/day for seven days. MATERIAL AND METHODS: Fifty Sprague-Dawley rats were studied, 10 in each group. Adhesions were induced through controlled rubbing of the cecum and suturing of an incision in the terminal ileum. Two independent observers recorded the degree of adhesion formation at 14 days and histologically studied the adhesions. STATISTICAL ANALYSIS: ANOVA compared group averages. The nonparametric Kruskal-Wallis test was used to identify group differences. RESULTS: The 0.5 mg/kg/day group had greater formation of adhesions (p < 0.001). There was no significant difference between the 1.5 and 2 mg/kg/day groups, though the latter group had an incidence of 27.2% of bleeding in the abdominal cavity. The degree of adhesions in the histological sections coincided with the macroscopic findings. The interobserver agreement was kappa = 0.88 (very good). CONCLUSION: The safe and effective dose of subcutaneous enoxaparin to prevent PAA formation was 0.5-1.5 mg/kg/day for seven days.

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INTRODUCTION: Acute pancreatitis (AP) is usually a mild and self-limiting disease, but some patients develop a severe form that is associated with high mortality. In AP, local inflammation is followed first by the systemic inflammatory response syndrome and then by the compensatory anti-inflammatory response syndrome, which is defined by low human leukocyte antigen (HLA)-DR expression on monocytes, increased concentration of the anti-inflammatory cytokine IL-10, and decreased monocyte function. Our aim was to measure the expression of triggering receptor expressed on myeloid cells (TREM)-1 (a proposed marker of infection or inflammation) and HLA-DR on monocytes, and the serum concentrations of IL-6 (a proinflammatory cytokine) and IL-10 in patients with AP to determine whether these markers can identify patients at high risk of developing severe AP or infection. METHODS: Fifty healthy volunteers, 18 patients with mild AP, and 11 patients with severe AP were included in this study. Samples were taken at admission and one and three days later. TREM-1 and HLA-DR expression was evaluated by flow cytometry, and soluble TREM-1, IL-6 and IL-10 concentrations were measured by ELISA. RESULTS: TREM-1 expression was higher in patients with AP than in healthy volunteers, but there was no difference between patients with mild and severe AP. TREM-1 expression was not associated with mortality or with the presence of infection. Soluble TREM-1 concentration in serum was higher in non-survivors than in survivors. HLA-DR expression was lower and IL-6 concentration higher in patients with severe AP and in infected patients. CONCLUSIONS: Increased TREM-1 expression was associated with the presence of inflammation but not infection in AP. In patients with AP, low HLA-DR expression and high IL-6 concentration could predict severity and infection in samples taken shortly after admission.

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In adults, diffuse haemangiomatosis of the liver is a very rare condition. The aetiology and clinical evolution are not well understood, and the literature records isolated cases with different behaviours and treatments. Here we present the case of a 45-year-old patient with haemangiomatose lesions in both lobes of the liver, causing moderate to intense abdominal pain and a bloated sensation in the presence of an abdominal mass, but with hepatic and haematological functions remaining largely intact. Conventional ultrasound and CAT scan revealed diffuse lesions in both hepatic lobes, and this required the performance of a diagnostic laparoscopy to rule out hepatic metasteses or multiple liver abscess. As the findings consisted of large blue-black spongy masses involving both lobes of the liver, radical treatment of a resective type was not possible. After two years of follow-up, the patient still complains of diffuse abdominal pain of varying intensity, which is being treated with analgesics. Liver function tests have demonstrated a gradual increase in both liver enzymes and alkaline phosphatase, but without frank clinical evidence of clinical liver insufficiency.

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Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow-up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post-surgical and histopathological diagnosis and post-surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post-surgical complication; in five of them, six surgical re-interventions were performed. Three deaths occurred in the 30-day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.

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Intraabdominal tumors require precise diagnosis for patient preparation for optimal surgical procedure. For diagnosis of these lesions, the principal studies used are ultrasonography, computed axial tomography (CAT) and occasionally the use of magnetic resonance imaging, a study not always possible to accomplish in all hospitals. We present the case of a patient with a giant retroperitoneal cyst whose diagnosis was missed by means of conventional ultrasound and CAT. For this reason, we chose to use ultrasound with echography using contrast agent (Levovist) to determine if the tumor was dependent on the liver or pancreas. By means of this technique, we were able to make the diagnosis that the tumor did not depend on any organ, but rather was an independent retroperitoneal tumor. Final surgical and histopathological diagnosis was a retroperitoneal multilocular lymphangioma. We conclude that ultrasonography with contrast agent (Levovist) is an alternative method for studying intraabdominal tumors.

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Los síntomas abdominales son frecuentes en el SIDA y el dolor abdominal es un reto diagnóstico que puede requerir cirugía electiva o urgente aunque la información acerca de esta última es pobre. En este estudio analizamos los hallazgos clínicos y evolución de pacientes con SIDA y dolor abdominal agudo. En un periodo de dos años, recolectamos variables demográficas y de laboratorio, síntomas clínicos, diagnóstico inicial, hallazgos quirúrgicos, diagnóstico postquirúrgico, hallazgos histopatológicos y complicaciones postoperatorias de pacientes con SIDA y dolor abdominal agudo. De 232 pacientes hospitalizados, 34 tuvieron dolor abdominal agudo: 32 hombres y 2 mujeres (mediana de edad = 32 años; intervalos 26 a 58). Veintidós pacientes requirieron manejo quirúrgico. Ocho pacientes presentaron complicaciones postquirúrgicas; cinco requirieron seis segundas intervenciones. Ocurrieron tres muertes en los 30 días luego de la cirugía inicial. La supervivencia para los pacientes tratados médicamente fue 4 meses (1 a 17), contra 6.5 meses (1 a 20) del grupo quirúrgico. El médico debe estar alerta acerca de las posibilidades diagnósticas del enfermo con SIDA y dolor abdominal agudo. Demorar la cirugía puede ser letal. La cirugía tiene un papel importante en el tratamiento integral del paciente con SIDA.

Abdominal symptoms frequently affect patients with AIDS. Acute abdominal pain is a diagnostic challenge that may require elective or urgent surgical treatment, although information about the latter is scarce. In this study we analyzed the clinical findings and follow up of acute abdominal pain complicating patients with AIDS. In a two-year period, we collected several variables from patients with AIDS and acute abdominal pain: demographic, laboratory, clinical symptoms, initial diagnosis, surgical findings, post surgical and histopathological diagnosis and post surgical complications. From 232 hospitalized patients, 34 had acute abdominal pain: 32 male and 2 women (median age = 32 years; range 26 to 58 years). Twenty-two patients required surgical treatment. Eight patients had a post surgical complication; in five of them, six surgical re interventions were performed. Three deaths occurred in the 30 day period after surgery. Survival for patients conservatively treated was 4 months (1 to 17 months), vs. 6.5 months (1 to 20 months) in the surgically treated group. Physicians should be aware about the several diagnostic possibilities of acute abdominal pain complicating patients with AIDS. Delay of surgery in these patients may be lethal. Surgery has an important role in the integral treatment of patients with AIDS.

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Mesenteric cyst is a tumor of multiple origins that surely are found more frequently than the literature report, at any rate, this tumor is uncommon. Because of absence of characteristic clinical findings, diagnosis cumbersome, until these cysts are of such a size that palpation becomes possible or when they cause compression to nearby viscera. Occasionally, diagnosis is made during surgery, even when it was emergency surgery. The present paper reports on three patients with mesenteric cyst found during surgery as emergency treatment. Histopathologic reports showed lymphangioma in two cases and leiomyosarcoma in one case, quite uncommon in this kind of lesion.

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A study was carried out to compare the use of two different tension-free surgical techniques, for the repair of primary inguinal hernia in cases without complications. The study was carried out on 91 consecutive patients who presented with primary and uncomplicated inguinal hernia. The patients were randomly divided into two groups. Group I consisted of 42 patients whose inguinal hernia was repaired by means of the application of a triangular flap rotated from the anterior sheath of the abdominal rectus muscle and then sutured to the inguinal ligament with non-continuous and nonabsorbable suture 00. Group II consisted of 49 patients whose inguinal hernia was repaired by tension-free hernioplasty, placing a mesh umbrella plug in the deep inguinal orifice and, if necessary, mesh reinforcement to the floor of the inguinal canal (the Gilbert technique). There were no statistically significant differences with regard to age, sex, hernia evolution time, trans- or postoperative complications, or hernia recurrence during an average follow-up time of 3 years. Patients in the flap group required significantly more surgery time and postoperative analgesics. Cost analysis showed that patients receiving a muscle sheath flap spent less money on the actual surgical procedure, given the saving on the purchase of a prosthetic mesh. However, when taking into account the greater need for analgesia and the longer time in the operating theater, there was no difference in overall cost between the two procedures. Inguinal hernia repair using a triangular flap from the anterior sheath of the abdominal rectus muscle is an additional surgical procedure that can be utilized in cases where prosthetic mesh repair is not feasible.

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