A65-year-old man presents with a 4-day history of worsening lower abdominal pain and constipation. On examination, he is febrile (38.5°C) and has lower a bdominal tenderness that is most intense in the midline and left lower quadrant associated with a palpable fullness. Laboratory findings demonstrate a moderate leukocytosis and abdominal roentgenograms show an ileus pattern. For the above patient with abdominal pain, select the most likely diagnosis.
A. gastroenteritis
B. regional enteritis
C. acute appendicitis
D. perforated peptic ulcer
E. sigmoid diverticulitis
F. acute pancreatitis
G. acute cholecystitis
H. superior mesenteric artery embolism
I. ruptured abdominal aortic aneurysm
J. ruptured ovarian cyst
K. cecal volvulus
Correct Answer: E
Acute appendicitis initially presents with periumbilical pain secondary to obstruction of the appendiceal lumen. This is mediated through visceral pain fibers, and because the appendix is from the embryologic midgut, the pain is referred to the umbilicus. With obstruction of a hollow viscus, there may be associated nausea. As the inflammatory process progresses to involve the visceral and parietal peritoneal surfaces, the pain becomes localized directly over the appendix in the right lower quadrant. Fever and leukocytosis are nonspecific signs of an inflammatory process. Gastroenteritis may be associated with nausea, anorexia, and lowgrade fever. Periumbilical pain is colicky and secondary to increased peristalsis. Localized pain and signs of peritoneal irritation are uncommon. Aruptured right ovarian cyst may mimic appendicitis. Patients may exhibit right lower abdominal peritoneal irritation. However, the onset of pain is usually sudden, and the pain is initially felt in the right lower quadrant.
These patients do not have anorexia or other gastrointestinal symptoms. The clinical picture of regional enteritis (Crohn's disease) is one of a chronic illness, often associated with weight loss, intermittent cramps, and diarrhea. Fever, tenderness, and a palpable right lower quadrant inflammatory mass may result from complications of ileal involvement. Sigmoid diverticulitis is more common in older patients, often with a prodromal history of irregular bowel habits. There may be left lower quadrant pain and tenderness, with a palpable left-sided inflammatory mass. A cecal volvulus presents with sudden onset of colicky abdominal pain and signs and symptoms of a bowel obstruction, including bilious emesis and abdominal distention. Alcohol-related acute pancreatitis presents with pain referred to the epigastrium, with radiation to the back mediated through the celiac ganglia. The patient may develop abdominal distention secondary to the associated paralytic ileus. Hyperamylasemia and an elevated serum lipase, in this clinical setting, are suggestive of pancreatitis. Perforated peptic ulcer and acute cholecystitis may also present with epigastric pain, and elevations of both serum lipase and amylase. Pain from a perforated ulcer, however, is sudden in onset and may be associated with shoulder-tip pain from diaphragmatic irritation. About 75% of patients with perforated duodenal ulcers have pneumoperitoneum on chest and abdominal radiographs.
Acute cholecystitis will usually commence after a large meal and initially presents as colicky epigastric pain, progressing to pain localized in the right upper abdomen when transmural inflammation of the gallbladder wall produces peritoneal irritation. Acute mesenteric occlusion presents with sudden onset of severe but poorly localized periumbilical abdominal pain, associated with acidosis. There may be elevation of serum amylase and lipase. A ruptured abdominal aortic aneurysm will present with sudden onset of midabdominal pain, back pain, and hemodynamic instability.
Question 162:
A40-year-old man with a history of alcohol abuse presents after an episode of binge drinking. He is complaining of epigastric pain, radiating to the back, associated with nausea and vomiting. On examination, he has marked tenderness in the epigastrium, with guarding, decreased bowel sounds, and moderate abdominal distention. Laboratory findings include leukocytosis and increased serum amylase and lipase. Abdominal roentgenograms demonstrate several dilated bowel loops in the upper abdomen. For the above patient with abdominal pain, select the most likely diagnosis.
A. gastroenteritis
B. regional enteritis
C. acute appendicitis
D. perforated peptic ulcer
E. sigmoid diverticulitis
F. acute pancreatitis
G. acute cholecystitis
H. superior mesenteric artery embolism
I. ruptured abdominal aortic aneurysm
J. ruptured ovarian cyst
K. cecal volvulus
Correct Answer: F
Acute appendicitis initially presents with periumbilical pain secondary to obstruction of the appendiceal lumen. This is mediated through visceral pain fibers, and because the appendix is from the embryologic midgut, the pain is referred to the umbilicus. With obstruction of a hollow viscus, there may be associated nausea. As the inflammatory process progresses to involve the visceral and parietal peritoneal surfaces, the pain becomes localized directly over the appendix in the right lower quadrant. Fever and leukocytosis are nonspecific signs of an inflammatory process. Gastroenteritis may be associated with nausea, anorexia, and lowgrade fever. Periumbilical pain is colicky and secondary to increased peristalsis. Localized pain and signs of peritoneal irritation are uncommon. Aruptured right ovarian cyst may mimic appendicitis. Patients may exhibit right lower abdominal peritoneal irritation. However, the onset of pain is usually sudden, and the pain is initially felt in the right lower quadrant.
These patients do not have anorexia or other gastrointestinal symptoms. The clinical picture of regional enteritis (Crohn's disease) is one of a chronic illness, often associated with weight loss, intermittent cramps, and diarrhea. Fever, tenderness, and a palpable right lower quadrant inflammatory mass may result from complications of ileal involvement. Sigmoid diverticulitis is more common in older patients, often with a prodromal history of irregular bowel habits. There may be left lower quadrant pain and tenderness, with a palpable left-sided inflammatory mass. A cecal volvulus presents with sudden onset of colicky abdominal pain and signs and symptoms of a bowel obstruction, including bilious emesis and abdominal distention. Alcohol-related acute pancreatitis presents with pain referred to the epigastrium, with radiation to the back mediated through the celiac ganglia. The patient may develop abdominal distention secondary to the associated paralytic ileus. Hyperamylasemia and an elevated serum lipase, in this clinical setting, are suggestive of pancreatitis. Perforated peptic ulcer and acute cholecystitis may also present with epigastric pain, and elevations of both serum lipase and amylase. Pain from a perforated ulcer, however, is sudden in onset and may be associated with shoulder-tip pain from diaphragmatic irritation. About 75% of patients with perforated duodenal ulcers have pneumoperitoneum on chest and abdominal radiographs.
Acute cholecystitis will usually commence after a large meal and initially presents as colicky epigastric pain, progressing to pain localized in the right upper abdomen when transmural inflammation of the gallbladder wall produces peritoneal irritation. Acute mesenteric occlusion presents with sudden onset of severe but poorly localized periumbilical abdominal pain, associated with acidosis. There may be elevation of serum amylase and lipase. A ruptured abdominal aortic aneurysm will present with sudden onset of midabdominal pain, back pain, and hemodynamic instability.
Question 163:
A21-year-old previously healthy woman presents with abdominal pain of 48-hour duration. The pain was initially periumbilical and on progression became localized in the right lower quadrant. The woman had nausea and a decreased appetite. She denied dysuria. Her last menstrual period was 2 weeks earlier. On examination, she was febrile (temperature 38.2°C), and was found to have localized tenderness in the right lower quadrant with guarding. Rectal examination was normal. Laboratory examination demonstrated mild leukocytosis. For the above patient with abdominal pain, select the most likely diagnosis.
A. gastroenteritis
B. regional enteritis
C. acute appendicitis
D. perforated peptic ulcer
E. sigmoid diverticulitis
F. acute pancreatitis
G. acute cholecystitis
H. superior mesenteric artery embolism
I. ruptured abdominal aortic aneurysm
J. ruptured ovarian cyst
K. cecal volvulus
Correct Answer: C
Acute appendicitis initially presents with periumbilical pain secondary to obstruction of the appendiceal lumen. This is mediated through visceral pain fibers, and because the appendix is from the embryologic midgut, the pain is referred to the umbilicus. With obstruction of a hollow viscus, there may be associated nausea. As the inflammatory process progresses to involve the visceral and parietal peritoneal surfaces, the pain becomes localized directly over the appendix in the right lower quadrant. Fever and leukocytosis are nonspecific signs of an inflammatory process. Gastroenteritis may be associated with nausea, anorexia, and lowgrade fever. Periumbilical pain is colicky and secondary to increased peristalsis. Localized pain and signs of peritoneal irritation are uncommon. Aruptured right ovarian cyst may mimic appendicitis. Patients may exhibit right lower abdominal peritoneal irritation. However, the onset of pain is usually sudden, and the pain is initially felt in the right lower quadrant. These patients do not have anorexia or other gastrointestinal symptoms. The clinical picture of regional enteritis (Crohn's disease) is one of a chronic illness, often associated with weight loss, intermittent cramps, and diarrhea. Fever, tenderness, and a palpable right lower quadrant inflammatory mass may result from complications of ileal involvement. Sigmoid diverticulitis is more common in older patients, often with a prodromal history of irregular bowel habits. There may be left lower quadrant pain and tenderness, with a palpable left-sided inflammatory mass. A cecal volvulus presents with sudden onset of colicky abdominal pain and signs and symptoms of a bowel obstruction, including bilious emesis and abdominal distention. Alcohol-related acute pancreatitis presents with pain referred to the epigastrium, with radiation to the back mediated through the celiac ganglia. The patient may develop abdominal distention secondary to the associated paralytic ileus. Hyperamylasemia and an elevated serum lipase, in this clinical setting, are suggestive of pancreatitis. Perforated peptic ulcer and acute cholecystitis may also present with epigastric pain, and elevations of both serum lipase and amylase. Pain from a perforated ulcer, however, is sudden in onset and may be associated with shoulder-tip pain from diaphragmatic irritation. About 75% of patients with perforated duodenal ulcers have pneumoperitoneum on chest and abdominal radiographs.
Acute cholecystitis will usually commence after a large meal and initially presents as colicky epigastric pain, progressing to pain localized in the right upper abdomen when transmural inflammation of the gallbladder wall produces peritoneal irritation. Acute mesenteric occlusion presents with sudden onset of severe but poorly localized periumbilical abdominal pain, associated with acidosis. There may be elevation of serum amylase and lipase. A ruptured abdominal aortic aneurysm will present with sudden onset of midabdominal pain, back pain, and hemodynamic instability.
Question 164:
A25-year-old man was admitted to the ICU with severe head injury with a basal skull fracture. Eighteen hours after the injury, he developed polyuria. Urine osmolality was 150 mOsm/Land serum osmolality was 350 mOsm/L. IV fluids were stopped, and 1 hour later urine output and urine osmolality remained unchanged. Five units of vasopressin were administered intravenously, and urine osmolality increased to 300 mOsm/L. Select the most likely diagnosis for each of the patients with polyuria.
A. central diabetes insipidus (DI)
B. nephrogenic DI
C. water intoxication
D. solute overload
E. diabetes mellitus
Correct Answer: A
DI is a disorder due to impaired renal conservation of water. DI presents with polyuria and dilute urine in the presence of an elevated serum osmolality. This is either secondary to impaired production of antidiuretic hormone (ADH) from the posterior pituitary (central DI), or refractoriness of the distal renal tubules to ADH (nephrogenic DI). Central DI may complicate closed-head injury, and is considered a poor prognostic sign. These patients will respond to exogenous IV vasopressin, with resultant increase in urine osmolality and decrease in urine volume. Nephrogenic DI may be congenital, familial, or acquired. Acquired nephrogenic DI may occur in the setting of repeated renal tubular insults such as sepsis, IV contrast, and nephrotoxic drug therapy. With administration of vasopressin, these patients will have no change in urine osmolality or urine volume because the renal tubules are unresponsive. DI must be differentiated from other causes of polyuria. Water intoxication results from ingestion of a large volume of fluid, with resultant dilutional hyponatremia. If the patient has a normal diluting capacity, there will be polyuria, with a proportionally low serum and urine osmolality. Prolonged fluid restriction will result in appropriate rise in urine osmolality. Osmotic diuresis may occur from solute overload when the renal tubules are unable to reabsorb adequate quantities of filtered solutes. This is associated with administration of mannitol or, in the presence of glycosuria, from diabetes mellitus.
Question 165:
A45-year-old man is brought to the emergency department after being involved in an automobile crash. He is alert and oriented, with a normal neurologic examination. His respiratory rate is 20/min, with clear lungs, pulse rate of 120/min, and blood pressure of 80/40 mmHg. On examination, he is noted to have a distended abdomen, with decreased bowel sounds, and a fracture of the right ankle. IV access is established, and the patient receives a rapid infusion of 2 L of saline, without changes to pulse rate or blood pressure. Which of the following is the most appropriate next step in his management?
A. abdominal CT scan
B. insertion of a Swan--Ganz catheter
C. exploratory laparotomy
D. focused abdominal sonography for trauma (FAST)
E. diagnostic peritoneal lavage
Correct Answer: C
This patient has a distended abdomen, with decreased bowel sounds, in the presence of shock that is unresponsive to aggressive fluid resuscitation. Intra-abdominal hemorrhage from solid visceral injury (hepatic, splenic, or renal) is the most likely etiology. The patient should undergo an urgent exploratory laparotomy and damage control (packing) for control of the bleeding, in conjunction with ongoing resuscitation with infusion of IV fluids and blood products. Although hypotension can result from a cervical cord injury, it is unlikely in this case, in the presence of a documented normal neurologic examination. ASwan-Ganz catheter is not indicated in the initial evaluation and management of a patient presenting in hypovolemic shock from blunt trauma. Abdominal CT scan is indicated only for evaluation of blunt abdominal trauma in patients who are hemodynamically stable. FAST and diagnostic peritoneal lavage may be indicated in the evaluation of patients with hypotension in which the source of bleeding is unclear. In this patient, however, the presence of a distended abdomen suggests hemoperitoneum, and therefore, FAST and lavage are not necessary
Question 166:
Apreviously healthy 19-year-old man presents to the emergency department with a penetrating wound to the right neck. There were reports of bleeding at the scene. The patient is talking, complaining of pain at the injury site and pain with swallowing. On examination, he has a normal respiratory rate, clear air entry on auscultation, blood pressure of 120/70 mmHg, and heart rate of 95 beats/min. There is a penetrating right neck wound in zone 2 (between the clavicle and the lower part of the mandible), with a surrounding hematoma. On probing, there is violation of the platysma. Which of the following is the best next step in the management of this patient?
A. intubation and observation in the ICU
B. admission to the ICU for close observation without intubation
C. observation in the ICU only if carotid angiogram is normal
D. observation in the ICU only if carotid angiogram, contrast esophagram, and bronchoscopy are normal
E. neck exploration
Correct Answer: E
The anterior triangle of the neck is divided into three zones: zone I at the base of the neck and thoracic inlet, zone II in the midbody of the neck, and zone III above the angle of the mandible. Zone II, the most common area injured with penetrating trauma, encompasses the carotid artery, jugular vein, larynx, trachea, and esophagus. Patients with penetrating injuries to the neck that violate the platysma should be admitted to the hospital for further evaluation. This patient has a penetrating injury through the platysma, in zone II of the anterior triangle. He has signs of significant injury (i.e., external bleeding at the scene, odynophagia, and a neck hematoma on examination). This patient should undergo surgical exploration, without prior diagnostic studies. Observation in the ICU, with or without intubation, is not appropriate in a patient with obvious clinical signs of injury. Furthermore, extensive preoperative imaging studies are not necessary for zone II injuries because surgical exposure of vital structures in this area of the neck is easily achieved. All patients with clinical signs of injury should undergo surgical exploration. However, there is controversy with respect to the management of patients without clinical signs of injury. There are two approaches: A. mandatory surgical exploration; or B. selective observation with or without imaging studies
Question 167:
A 25-year-old previously healthy man is scheduled for elective inguinal hernia repair under general
anesthesia. After induction of anesthesia and initial inguinal incision, the patient develops tachycardia,
muscle rigidity, fever of 38.5°C, and elevated end- tidal carbon dioxide.
Which of the following is the most likely diagnosis?
A. pneumonia
B. atelectasis
C. urinary tract infection
D. myocardial infarction
E. malignant hyperthermia
Correct Answer: E
Malignant hyperthermia may occur after administration of certain inhalation agents for induction of general anesthesia or with succinylcholine for muscle relaxation. This is a result of a genetic defect in calcium release from the sarcoplasm of skeletal muscle. It often occurs within 30 minutes of induction, and in addition to fever, tachycardia, and muscle rigidity, there is a metabolic acidosis and hyperkalemia. The treatment is administration of dantrolene to block calcium release from the sarcoplasm and insulin/ bicarbonate/dextrose infusion to treat the hyperkalemia. Diagnosis is confirmed by muscle biopsy. Pneumonia is an infective, inflammatory process; is not associated with muscle rigidity; and is not likely to have a rapid progressive onset after induction of anesthesia in a previously healthy patient. Atelectasis is unlikely under general anesthesia, particularly in patients receiving positive pressure ventilation. Although pyelonephritis may be associated with fever, it is not associated with muscle rigidity or metabolic acidosis and would be unlikely to become symptomatic after induction in an otherwise healthy patient. Myocardial infarction may be associated with tachyarrhythmias but would not account for the muscle rigidity, fever, or metabolic acidosis and, in the absence of risk factors, would be very unlikely in this healthy patient.
Question 168:
A70-year-old man presents with back pain and increasing difficulty with initiating a urinary stream. On rectal examination, he is found to have a hard, irregularly enlarged prostate. He has an elevated prostate-specific antigen (PSA), and osteoblastic lesions in the vertebral column and bones of the pelvis. Aneedle biopsy of the prostate shows well-differentiated adenocarcinoma. Which of the following is the treatment of choice?
A. radical prostatectomy
B. transurethral prostatectomy
C. cytotoxic chemotherapy
D. hormonal manipulation
E. radiotherapy
Correct Answer: D
This elderly patient has metastatic adenocarcinoma of the prostate, and management is, therefore, aimed at tumor control for palliation of symptoms. This is achieved with hormonal manipulation, either by orchiectomy or exogenous estrogen therapy. Radical prostatectomy is indicated only for patients in whom the malignancy is confined to the prostate gland. Transurethral prostatectomy is used to treat benign prostatic hypertrophy, and is not considered adequate surgical therapy for prostatic malignancy. Cytotoxic chemotherapy may be useful as an adjunct to radical surgical excision of localized disease. Chemotherapy is not indicated for the treatment of metastatic disease. Radiation therapy has been used for the management of localized disease, and there is some evidence that it affords equivalent survival when compared to surgical excision. In patients with bone pain that is not well palliated with hormonal manipulation, radiation therapy may be useful.
Question 169:
A13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal
pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination,
he is in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right
testes.
CBC and urinalysis are normal.
Which of the following is the most appropriate next step in management?
A. admit the patient to the hospital and place him on bed rest
B. analgesics and a scrotal support
C. antibiotic therapy
D. schedule a testicular isotope scan
E. urgent surgical exploration
Correct Answer: E
Testicular torsion presents with acute onset of scrotal pain, reflex vomiting, referred abdominal pain, and an elevated tender testis. If there is a high index of suspicion based on history and clinical examination, the patient should undergo an urgent surgical exploration. Delay in definitive therapy increases the risk of testicular loss secondary to ischemia. Isotope scan may demonstrate absence of testicular blood flow in torsion, and increased flow in orchitis or epididymitis. Although useful in the differential diagnosis, these nuclear medicine studies may not be readily available, and definitive therapy should not be delayed awaiting imaging. Orchitis and epididymitis present with a more insidious clinical course associated with the progression of the inflammatory process. There may be a concomitant urinary tract infection, and therapy includes analgesics and antibiotics.
Question 170:
A 55-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Initial management should include which of the following?
A. antibiotics and IV fluids
B. lactose-free diet
C. antispasmodics
D. nutritional supplementation and systemic steroids
E. laparotomy
Correct Answer: D
Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract that presents with intermittent crampy abdominal pain and diarrhea. It most commonly involves the terminal ileum and right colon. Because eating can exacerbate symptoms, oral intake may be decreased, contributing to the associated weight loss. Transmural inflammation leads to bowel wall thickening, and with adjacent mesenteric inflammation, the patient may develop a palpable mass. It may be difficult to differentiate Crohn's disease from ulcerative colitis on the basis of history and clinical examination.
However, ulcerative colitis is a mucosal disease that is limited to the colon and nearly always involves the rectum. Diarrhea is usually bloody, and hemorrhage may be significant enough to require transfusion therapy. Complicated appendicitis may present with a right lower quadrant mass and diarrhea if there is perforation with abscess formation. The history is that of an acute illness in a previously well patient. Irritable bowel syndrome is associated with intermittent crampy abdominal pain, and diarrhea alternating with constipation. There is no inflammatory process, and weight loss is not a clinical feature. Evaluation of the small bowel is best accomplished with contrast radiography, such as a small-bowel follow-through study or enteroclysis. Radiographic abnormalities of small-bowel Crohn's disease are often distinctive and can demonstrate complications such as strictures and fistulae. CT scanning does not assist in confirming the diagnosis, but is helpful in detecting such complications as abscess. Ultrasonography has limited value. Sigmoidoscopy may not be useful, because Crohn's disease commonly spares the rectum and may be worse on the right side of the colon. Colonoscopy may be helpful when the colon is involved and when intubation of the ileocecal valve can be achieved; however, the disease may be limited to the small bowel resulting in a nondiagnostic examination.
The principle of initial management of Crohn's disease is relief of symptoms, nutritional therapy, and suppression of the inflammatory process. Nutritional supplementation may require TPN in conjunction with bowel rest. Acute exacerbations of the disease are initially treated with systemic steroids. The use of antispasmodics may be effective in the treatment of irritable bowel syndrome. In Crohn's disease, however, antispasmodics may lead to an ileus or toxic bowel dilatation. Surgery in Crohn's disease is indicated for the management of complications, including fistula or abscess formation, stricture with obstruction, and perforation.
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