Question of the Week # 460


A 65-year-old woman with a previous medical history of diabetes and rheumatoid arthritis underdoes an exploratory laparotomy for perforated sigmoid diverticulitis. Her postoperative stay is prolonged because of pneumonia, but is extubated on the fifth postoperative day and the next day discharged from the ICU to the floor. You are called by the nurse to check her wound as she noticed a new serous discharge. Her temperature is 37.0 C (98.6 F), pulse 100 beats/min, blood pressure 140/80 mm Hg, and blood glucose by finger stick 240 mg/dl. Abdomen is soft and non-tender. There is no induration, erythema, or crepitus of the wound. Copious amounts of serous brownish liquid are expressed from the wound on gentle pressure. Fluid is expressed spontaneously on coughing from both upper and lower parts of the wound. Which of the following is the most appropriate next step?
A. Start the patient on an insulin drip
B. Stop anticoagulation with subcutaneous heparin
C. Order dry dressings to be continued
D. Prescribe a 1-week course of antibiotics
E. Schedule the patient for wound exploration in the operating room

Question of the Week # 459

459) A 56-year-old man comes to the clinic complaining of postprandial nausea, occasional vomiting, and abdominal pain. Upon further questioning, he describes intermittent diarrhea and cramps, as well as diaphoresis, palpitations, and flushing. Three months ago he underwent resection of the distal stomach and proximal duodenum and gastrointestinal reconstruction due to complicated peptic ulcer disease. Prior to the operation, he had similar abdominal pain but it was usually relieved, not worsened with eating. Vital signs and physical examination are unremarkable. The most appropriate next step in the management of this patient is which of the following?
A. Begin a trial of somatostatin
B. Counsel the patient about his diet
C. Determine the patient’s gastrin level
D. Order a CT scan of the abdomen
E. Schedule a repeat endoscopy

Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration
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