Question of the Week #482

A 63-year-old woman comes to the emergency department complaining of severe midabdominal pain. She reports that the pain has increased in intensity over the past few days. There has been no associated nausea or vomiting, no change in bowel habits, and no relief afforded by position changes. She is postmenopausal and does not take hormone replacement therapy. She has a 30-year history of hypertension, and has been noncompliant with her therapy of calcium channel blocker and thiazide diuretic. On examination her abdomen is obese but there is a suggestion of a nontender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following is the best next step in management?

A. Abdominal ultrasound
B. Abdominal CT scan without contrast
C. Abdominal CT scan with contrast
D. Angiography
E. Observation

Question of the Week # 463

463) A 48 year old woman presents to the emergency room with significant pain in the epi-gastrium and right upper quadrant. The pain has been persistent for the past 8 hours. She rates her pain at 8/10 in intensity. She reports some nausea but has not vomited. She has no jaundice. She denies any cough or burning urination or hematuria. On examination, she is obese, temperature is 99.9 F, blood pressure is at 120/80. She does not have any pallor or icterus. She lies still on the examination table since any movement aggravates her pain. She demands pain medication before you can examine her. An ultrasound of the abdomen is pending. What is the most appropriate next step?

A) Tell her that physical exam is done before analgesics since analgesia may obscure the diagnosis.
B) Give her morphine sulfate
C) Give her Meperidine
D) Obtain Urine drug screen
E) Tell her that you will not treat her pain without doing physical exam first

Question of the Week # 460

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

Question of the Week # 432

432) A 62-year-old man presents with painless, progressive enlargement in the left side of his neck over the past 3 months. He denies any fever, night sweats or chills. He denies any pain, dysphagia, cough, hemoptysis, chestpain, shortness of breath, history of trauma or dental infection. His past medical history is significant for  100 pack-year history of smoking and daily alcohol abuse. On examination, he is afebrile. He has a large 5 cm , hard, non-tender and matted lymphadenopathy on the left lateral aspect of his neck . He has no other lymph node enlargement. No rash. Reminder of the exam including oral cavity examination is normal. There are no obvious tongue, pharyngeal or tonsillar lesions.  HIV and VDRL are negative. A CT scan of the chest, abdomen and pelvis does not reveal any lymphadenopathy or obvious mass lesions. Which of the following is the most appropriate next step in management?

A) Open biopsy of the neck mass

B) Pan-endoscopy

C)  Fine Needle Aspiration Cytology ( FNAC)

D) Test for HPV ( Human Papilloma Virus) and EBV ( Ebstein Barr Virus)

E) Prescribe antibiotic therapy and re-evaluate in 4 weeks

Question of the Week # 428

428) A 32-year-old male boxer presents to the emergency room after sustaining an injury during a local boxing match.  He was punched by the opponent over his right ear about six hours ago . He complains of pain and swelling over his right ear. He has no hearing deficit or tinnitus or headaches or blurred vision. He denies nausea or vomiting. Past medical history is unremarkable. On examination, his vitals are stable. His right ear is red, warm and swollen with a medium sized anterior auricular swelling which is tender to palpation. There is no facial swelling. If untreated, which of the following would be most likely course of this injury?

A) Spontaneous Resolution

B) Hearing Deficit

C) Permanent ear disfigurement

D) Otitis Externa

E) Mastoiditis

Question of the Week # 427

427) A 32-year-old male boxer presents to the emergency room after sustaining an injury during a local boxing match.  He was punched by the opponent over his right ear about six hours ago . He complains of pain and swelling over his right ear. He has no hearing deficit or tinnitus or headaches or blurred vision. He denies nausea or vomiting. Past medical history is unremarkable. On examination, his vitals are stable. His right ear is red, warm and swollen with a medium sized anterior auricular swelling which is tender to palpation. There is no facial swelling. Which of the following is the most appropriate management?

A) Compressive dressing

B) Needle aspiration of the Hematoma

C) Cold compresses, analgesics and antibiotics

D) Incision and Drainage

E) Observe and await  spontaneous hematoma resolution

Question of the Week # 373 and 374

373)  A 70 year old woman presents to the emergency room with complaints of abdominal pain for the past one day. The pain is in in lower abdomen and is mild to moderate. It has started suddenly and is persistent. She also reports  having had two episodes of  loose and bloody stools this morning. Her past medical history is significant for coronary artery disease, hypertension and chronic kidney disease. On examination, she is afebrile, blood pressure is 130/80 mm Hg, pulse 90/min and respiratory rate 18/min. Cardiac examination reveals normal and regular heart sounds without murmurs. There is tenderness in the left lower quadrant of the abdomen. There is no rebound tenderness or rigidity. The patient is started on intravenous fluids. Stool studies reveal blood but no leukocytes. Clostridium difficle toxin is negative. Stool cultures are sent. Complete blood count shows White blood cell count at 20,000/µl with left shift. She is started on IV hydration. Which of the following is the most likely diagnosis?

A) Mesenteric Infarction

B) Acute Diverticulitis

C) Acute Mesenteric Ischemia

D) Ischemic Colitis

E) Inflammatory Bowel Disease

374) The patient in the above question undergoes appropriate diagnostic work up and the diagnosis is confirmed. Which of the following is the most appropriate next step in management ?

A) Broad spectrum antibiotics

B) Mesenteric angiography

C) Obtain Surgery Consult

D) Percutaneous Transluminal Angioplasty and Mestenteric stent

E) Start Methylprednisolone and Mesalmaine

Question of the Week # 372

372)  A 65 year old man presents to the Emergency room with complaints of severe abdominal pain that began 30 minutes ago while at rest. He reports diffuse pain that all over his abdomen, the lower back as well as in the flanks. His past medical history is significant for diabetes mellitus and peripheral vascular disease. He denies any abdominal trauma. He smokes about 1 pack cigarettes per day . On examination, he is in severe distress secondary to pain. He is afebrile, blood pressure is 80/40 mm Hg, pulse 120/min and respiratory rate 24/min. Abdomen is mildly distended with mild tenderness and a palpable pulsatile mass. Femoral and dorsalis pedis pulses are diminished.  An electrocardiogram reveals sinus tachycardia. The patient is started on intravenous fluids and is placed on a cardiac monitor. Which of the following  is the most appropriate next step?

A) CT scan of the abdomen

B) Exploratory laporotomy

C) Cardiac enzymes

D) Focused Abdominal Sonography in Trauma ( FAST)

E) Start Insulin Drip.

Question of the Week # 371

371)  A 45 year caucasian man is evaluated in your office prior to surgery for refractory heartburn symptoms. He was diagnosed with Gastro-esophageal reflux disease 2 years ago. Initially, his disease was mild and was responsive to over the counter antacids. He was started on PPI ( proton pump inhibitor trial 6 months ago and has not responded. He switched physicians and tried different brands of proton pump inhibitors with no benefit. An endoscopy was performed a year ago and repeat endoscopy 3 months ago revealed erosions and inflammations consistent with reflux esophagitis with out any background of barrett’s esophagus. The patient is scheduled for fundoplication surgery and is here for pre-operative evaluation. Which of the following should be performed at this time ?

A) 24 hour esophageal pH monitoring

B) Barium esophagogram

C) Esophageal motility studies

D) No additional tests needed , clear patient  for surgery

E) H.Pylori Urea Breath Test

Question of the Week # 306

306) A 32 year old man with history of immune thrombocytopenic purpura is evaluated in your office during a follow up visit. His previous treatments include intravenous immunoglobulin (IVIG) and steroids for his immune thrombocytopenia. He has responded to IVIG in the past however, the response was transient despite steroid maintenance. The patient was maintained on steroids for 2 months initially and achieved a sub-optimal response with peak platelet count reaching 30k/µl. He began very slow steroid taper over the last 4 weeks but his platelets have dropped to 8k/μl again during the taper. Hence, the patient is scheduled for Splenectomy. On examination, he has no bleeding or echymoses. Platelet count today is 10k/μl. Which of the following is the most appropriate step in preparing this patient for surgery?

A) Pneumococcal , Meningococcal and HIB vaccines 1 week prior to surgery

B) Pneumococcal and meningococcal vaccines 2 weeks prior to surgery

C) Pneumococcal, Menigococcal and HIB vaccines 2 weeks prior to surgery

D) Daily oral Penicillin Prophylaxis

E) No vaccines required in adults

Question of the week # 299

299) A 10 month old male infant  is brought by his concerned mother to the Emergency room with complaints of vomiting and bloody diarrhea. Mother reports that he suffered from “stomach flu” symptoms about 1 week ago which resolved spontaneously.  He had 4 episodes of vomiting since yesterday and has been crying intermittently every 15 minutes. There is no blood or bile in the vomitus. He had four loose stools with blood in it. There is no history of fever or cough or cold. His past medical history is unremarkable. On examination, temperature is 98.4F,  pulse 112, respiratory rate 30/min and blood pressure at 80/50 mm hg. Oral mucosa appear moist and skin turgor is adequate. Abdomen is soft with no palpable masses. Bowel sounds are present. Stool guaiac is strongly positive. Stool is sent for cultures and abdominal x-rays are obtained. An x-ray image is shown below:

Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Gastrograffin enema

C) Surgery

D) Rectal tube placement

E) Flexible sigmoidoscopy

Question of the week # 297

297) A 64 year old man is seen in the office for pre-operative evaluation of right inguinal hernia repair. His past medical history is significant for diabetes and recurrent right foot cellulitis. His most recent episode of right foot cellulitis was 2 weeks ago for which he received a 2 week course of oral antibiotics. His surgery is scheduled within one week. On examination, he is afebrile. He has reducible right inguinal hernia and bilateral lower extremity stasis dermatitis. His laboratory investigations reveal:

Platelet Count 240k/μl ( Normal 150–400k/μl)

Prothrombin time 22 seconds ( Normal 10 to 13 secs)

Partial Thromboplastin time : 34 sec ( Normal 22 to 37 secs)

Which of the following is the most appropriate action at this time?

A) Obtain PTT mixing studies

B) Administer Oral Vitamin K

C) Intravenous Fresh Frozen Plasma

D) Intravenous Factor VIII

E) Von Willebrand Factor Assay

Question of the week # 294

294) A 71 year old woman presents to the emergency room with complaints of bright red bleeding per rectum. She denies any abdominal pain, nausea or vomiting. She has a history of paroxysmal atrial fibrillation. Her medications include aspirin and beta blocker. About 10 days ago, she had a screening colonoscopy. She had a 3cm polyp in the sigmoid colon which was removed at that time.  She reports that she did not experience any bleeding immediately after polyp removal and is concerned about this episode that occured so many days after the procedure. On physical examination she is afebrile . Abdominal examination is benign. Rectal examination reveals bright red blood and no palpable hemorrhoids. Patient is anxious about her diagnosis.  Which of the following is the most appropriate statement?

A) ” Your bleeding is mostly secondary to ischemic colitis”

B) ” Bleeding can occur up to two weeks after polypectomy”.

C) ” Your bleeding is related to Aspirin use”.

D)  ” We will have to repeat colonoscopy to confirm that a cancer has not been missed”

E) ” You will need diagnostic laporoscopy to evaluate the cause”

Question of the week # 293

293) A 70 year old man is evaluated in the emergency room for abdominal pain , fever, nausea and vomiting that began 8 hours after he underwent a screening colonoscopy. The pain is severe and is mostly in the left lower quadrant of the abdomen. He reports that his colonoscopy procedure was uneventful except that he had a 2cm sessile polyp which was removed during the procedure. He denies any rectal bleeding. On examination, temperature is 102 F, blood pressure 100/60 mmHg, pulse 120, respiratory rate 28/min. Abdominal examination reveals severe tenderness,  guarding and rigidity in the left lower quadrant. Laboratory investigations show:

WBC 28k/µl with left shift

Hemoglobin 13.5 g/dL

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most important next step in management?

A) Obtain urgent surgical consult

B) Rectal tube placement

C) Serum amylase level

D) Supportive care alone

E) Barium enema

Question of the week # 292

292) A 66 year old man is evaluated in the emergency room for abdominal pain and fever. The patient underwent a screening colonoscopy in the outpatient Gastroenterology clinic 8 hours ago and had a 3cm sessile polyp removed. He complains of moderate pain in left lower quadrant that started one hour ago. He denies nausea or vomiting or rectal bleeding. On examination, temperature is 100.8F, blood pressure 140/90 mmHg, pulse 102, respiratory rate 20 bpm. Abdominal examination reveals tenderness and guarding in the left lower quadrant. There is no rigidity or rebound tenderness. His laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits. Which of the following is the most appropriate next step in managing this patient?

A) Exploratory Laporotomy

B) Rectal tube placement

C) Flexible sigmoidoscopy

D) CT Scan of the Abdomen

E) Conservative management

Question of the Week # 245

245 )  A 52-year-old man presents with acute onset of pain in his left testis which started abruptly after unprotected sexual intercourse. The pain started 3 hours ago, it is severe and constant. He denies any fever, chills, nausea or vomiting. On physical examination, the patient is afebrile and in severe distress. Testcular examination reveals a normal sized diffusely tender left testicle. Cremasteric reflex is absent on the left. A routine testicular ultrasound reveals normal testicles. A Complete Blood Count and Urinalysis are normal. What is the next step in management of this condition?

A)     Observation and Antibiotics

B)      Surgical exploration

C)      Repeat Testicular Doppler Ultrasound

D)     Laparotomy

E)      Observation alone

Question of the Week # 244

244 )  A 10-year-old Caucasian boy presents with right scrotal pain of 7 hours duration. The pain is acute in onset, constant and does not change with position. The patient denies any fever, chills, dysuria, nausea or vomiting. He denies any recent history of trauma. On physical examination, the patient is afebrile and is in moderate distress secondary to pain. There is no urethral discharge. Cremasteric reflex is present bilaterally. There is bluish discoloration and localized tenderness in the upper part of the testes. Labs reveal a normal Complete Blood Count and Urinalysis. What is the most likely clinical diagnosis in this patient?

A)     Testicular torsion

B)      Strangulated Hernia

C)      Congenital Hydrocele

D)     Torsion of Testicular appendix

E)      Acute Epidydimitis

 

 

 

 

Question of the Week # 230

230) A 72-year-old white man with history of type 2 diabetes mellitus and hypertension is evaluated in your office during a follow up visit. He was discharged 3 days ago from the hospital after undergoing diagnostic cardiac catheterization for an abnormal exercise stress test. Femoral sheath was removed three days ago. He denies any chest pain or shortness of breath.  On physical examination, he is afebrile, HR 120/min and blood pressure is 120/70 mm hg.  There is a new palpable mass in the right groin and systolic bruit is heard at the catheter insertion site. Dorsalis pedis and posterior tibial pulses are intact. Which of the following is the most likely diagnosis?

A)     Arterio-venos fistula

B)     Local Hematoma

C)      Femoral artery true aneurysm

D)     Hematoma in continuity with arterial lumen

E)     Femoral artery thrombosis

Question of the Week # 216

216 )  A 75 year old woman with past medical history of hypertension and diabetes is evaluated in your office for 20 lb weight loss. She reports decreased appetite and depressed mood for the past 6 months. Her history is significant for chronic smoking 1 pack per day for last 50 years. She lives alone and does all her daily activities by herself.  She has no known cardiac problems. She denies shortness of breath or cough. On examination, scleral icterus is noted. Lab studies show total bilirubin elevated at 10gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass. There are no distant metastases. A chest X-Ray is normal. CA 19-9 level 1400U/ml.  Which of the following is the most appropriate next  step ?

A) Hospice Evaluation

B) Surgical resection

C) Fine needle aspiration biopsy

D) Chemotherapy

E) Radiation therapy

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