EM: Practice Questions
A 29-year-old man presents to the ED complaining of RLQ pain for 24 hours. He states that the pain first began as a dull feeling around his umbilicus and slowly migrated to his right side. He complains of nausea and vomited twice. His BP is 130/75 mm Hg, HR is 95 beats/minute, RR is 16 breaths/minute, and temperature is 100.9°F. His WBC is 14,000/μL. As you palpate the LLQ of the patient's abdomen, he states that his RLQ is painful. What is the name of this sign? A. Blumberg sign B. Psoas sign C. Obturator sign D. Rovsing sign
Answer: D Explanation: *Rovsing sign is the referred tenderness to the RLQ when the LLQ is palpated.* It is seen in patients with acute appendicitis. Blumberg sign (a) is the occurrence of a sharp pain when the examiner presses on McBurney point and then releases pressure suddenly. This sign is indicative of peritoneal inflammation. The Psoas sign (b) is the increase of pain when the psoas muscle is stretched as the patient extends his or her hip, and is seen in appendicitis. The Obturator sign (c), another test for appendicitis, is the elicitation of abdominal pain as the hip is flexed and internally rotated.
A 2-year-old girl brought in by emergency medical services (EMS) because of a seizure. Upon EMS arrival at the child's home, the seizure had stopped and the child was slowly returning to baseline. Mother states the child was shaking with her eyes rolled back for 2-3 minutes. Past few days, the child has been coughing with runny nose. In the emergency department, you evaluate an interactive child who is clinging to her mother's side. Her right tympanic membrane is red and bulging with yellow effusion. Vital signs reveal fever otherwise normal. You determine the child had a simple febrile seizure and proceed to: A. Consult a pediatric neurologist B. Obtain a CBC, urinalysis, and cultures C. Order a head CT D. Prescribe course of amoxicillin and discharge home
Answer: D Explanation: Findings consistent with simple febrile seizure require reassurance with supportive care measures and antibiotic for the child's otitis media. If a focal seizure, abnormal neurologic exam, and prolonged seizure, then neuroimaging may be part of the patient's evaluation. *American Academy of Pediatrics does not recommend blood studies, neuroimaging, or EEG for simple febrile seizures.*The primary care provider can follow up the child without the involvement of a neurologist for simple febrile seizures.
A 27-year-old woman presents to the ED complaining of an intensely pruritic rash all over her body, abdominal cramping, and chest tightness. She states that 1 hour ago she was at dinner and accidentally ate some shrimp. She has a known anaphylactic allergy to shrimp. Her BP is 115/75 mm Hg, HR is 95 beats/minute, RR is 20 breaths/minute, temperature is 98.9°F, and oxygen saturation is 97% on room air. She appears anxious, and her skin is flushed with urticarial lesions. Auscultation of her lungs reveals scattered wheezes with decreased air entry. Which of the following is the most appropriate next step in management? A. Administer oxygen via nonrebreather, place a large-bore IV, begin IV fluids, and administer methylprednisolone intravenously B. Administer oxygen via nonrebreather, place a large-bore IV, begin IV fluids, and administer methylprednisolone and diphenhydramine intravenously C. Administer oxygen via nonrebreather, place a large-bore IV, begin IV fluids, administer methylprednisolone and diphenhydramine intravenously, and give intramuscular epinephrine D. Administer oxygen via nonrebreather, place a large-bore IV, begin IV fluids, and start aerosolized albuterol E. Administer oxygen via nonrebreather, place a large-bore IV, begin IV fluids, and start aerosolized epinephrine
Answer: C Explanation: The patient is having an anaphylactic reaction to the shrimp she ate. Anaphylaxis refers to a severe systemic allergic reaction with variable features such as respiratory difficulty, cardiovascular collapse, pruritic skin rash, and abdominal cramping. *Anaphylaxis is a hypersensitivity reaction caused by an IgE-mediated reaction.* Common foods that cause anaphylaxis include nuts, shellfish, and eggs. In the ED, attention is focused on reversing cardiovascular and respiratory disturbances. *Epinephrine is the first drug of choice for patients with anaphylaxis.* The route of administration is chosen by the severity of the patient's presentation. In a patient with severe upper airway obstruction or worsening hypotension, IV epinephrine should be administered. Patients with relatively stable vital signs can receive intramuscular epinephrine. Epinephrine should be used with caution in the elderly or any patient with coronary artery disease or dysrhythmias. However, in severe anaphylaxis, epinephrine can be life saving. Antihistamines, both H1 antagonists (diphenhydramine) and H2 antagonists (ranitidine and famotidine), should be used in all cases. These drugs block the action of circulating histamines at target tissue receptors. Corticosteroids, such as methylprednisolone, have an onset of action approximately 4 to 6 hours after administration and, therefore are of limited value in the acute setting. However, since giving them early may blunt the biphasic reaction of anaphylaxis, therefore, it is advised to administer to patients in anaphylaxis.
A 42-year-old man presents to the ED via ambulance after activating EMS for dyspnea. He is currently on an oxygen facemask and was administered one nebulized treatment of a β2-agonist by the paramedics. His initial vitals include a RR of 16 breaths/minute with an oxygen saturation of 96% on room air. The patient appears to be in mild distress with some intercostal retractions. Upon chest auscultation, there are minimal wheezes localized over bilateral lower lung fields. The patient's symptoms completely resolve after two more nebulizer treatments. Which of the following medications, in addition to a rescue β2-agonist inhaler, should be prescribed for outpatient use? A. Magnesium sulfate B. Epinephrine injection (EpiPen) C. Corticosteroids D. Cromolyn sodium E. Ipratropium
Answer: C Explanation: *Corticosteroids have been shown to improve asthma symptoms in subsequent days after an exacerbation and prevent acute recurrences in patients who are deemed suitable to be discharged from the ED.*An acceptable dosage is 40 to 60 mg prednisone daily for 3 to 10 days after the initial event. Inhaled steroids may also be an alternative to prevent relapses in more intractable cases, and should be used daily with the guidance of the patient's primary care provider. Spacers are available to ensure adequate delivery of medications deep into the alveoli.
A 34-year-old male with no past medical history presents to the ED complaining of 1 day of nausea, vomiting, and epigastric pain after drinking "a lot" over the weekend. He denies hematemesis, bright red blood per rectum or melena. He states that he has never been much of a drinker but drank excessively this weekend when some college friends were in town. He has vomited more than 15 times and has not been eating much because of the nausea and vomiting. His finger stick glucose is 97 and his vital signs are stable. His exam is significant for dry mucous membranes. He is anicteric. His abdomen is soft with mild discomfort in the epigastric region with no abdominal distention, masses, rebound, or guarding. Which of the following is MOST important in determining the patient's diagnosis? A. Electrolytes B. Improvement with GI cocktail. C. Lipase D. Ultrasound of gallbladder E. Urine ketones
Answer: A Explanation: Although alcoholic ketoacidosis (AKA) is most common in chronic alcoholics, it also occurs in first-time binge drinkers. Patients usually present with nonspecific complaints of abdominal pain, nausea, and vomiting. The anion gap in AKA is positive and ranges between 16 and 33 and is caused by ketonemia, primarily from β-hydroxybutyrate. The blood glucose ranges from low to mildly elevated. Urine ketones may be often low or negative initially as the nitroprusside reagent used to measure urine and serum ketones only measure acetoacetate. Acetone and β-hydroxybutyrate are not reactive and are more common early in the process of AKA. Gastritis can accompany AKA; however, improvement of symptoms with a "GI cocktail" does not rule out AKA, and without a high suspicion, AKA might be missed. Pancreatitis may also accompany AKA, but this patient does not have a history and physical consistent with pancreatitis. The patient's exam and history are also not consistent with gallbladder disease, so an ultrasound would not aid in making the diagnosis of AKA.
A 20-year-old man involved in a motor vehicle accident is brought into the emergency room having lost much blood at the accident scene. His initial blood pressure is 80/40 mm Hg and heart rate 130 beats per minute. He is given 3 L of normal saline intravenously and is still hypotensive. Which of these statements most accurately describes the pathophysiology of his condition? A. Insufficient cardiac preload B. Insufficient myocardial contractility C. Excessive systemic vascular resistance D. Excessive IL-6 and leukotrienes
Answer: A Explanation: In situations of trauma and hemorrhage, persistent hypotension is caused by blood loss unless otherwise proven, leading to reduced preload. Preload is end-diastolic sarcomere length, and insufficient circulating volume does not allow for sufficient venous return or cardiac output.
A 60-year-old man is brought to the ED complaining of generalized, crampy abdominal pain that occurs in waves. He has been vomiting intermittently over the last 6 hours. His BP is 150/75 mm Hg, HR is 90 beats/minute, RR is 16 breaths/minute, and temperature is 99.8°F. He has an old midline scar across the length of his abdomen from a surgery after a gunshot wound as a teenager. His abdomen is distended with hyperactive bowel sounds and mild tenderness without rebound. An abdominal plain film reveals dilated bowel loops and air-fluid levels. Which of the following is the most appropriate next step in management? A. Begin fluid resuscitation, place a NG tube, and request a surgical consult B. Begin fluid resuscitation, IV antibiotics, and admit the patient to the medical service C. Begin fluid resuscitation, administer a stool softener and an enema D. Begin fluid resuscitation, IV antibiotics, and observe the patient for 24 hours E. Order an abdominal ultrasound, and administer antiemetics and analgesics
Answer: A Explanation: The patient's clinical picture is consistent with a SBO. Fluid resuscitation is important because of fluid losses from vomiting compounded by the inability of the distended bowel to absorb fluid and electrolytes at a normal rate. If uncorrected, fluid losses can lead to hypovolemia and shock. Nasogastric suction is helpful by decompressing the stomach and removing accumulated gas and fluid proximal to the obstruction. Although some patients with SBO can be managed conservatively, a surgical consult is necessary because definitive treatment may require surgery to relieve the obstruction.
A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A. Chest x-ray B. Sputum gram stain C. Peak flow D. Ventilation-perfusion scan
Answer: C Explanation: *A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.* A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above. Sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia. A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patientabove does not have any risk factors that would lead you to suspect such a diagnosis.
A 31-year-old man without significant past medical history presents to the ED complaining of severe pain in his left flank that radiates to his left testicle. It waxes and wanes in intensity. He also noticed some blood in his urine in the morning. He had an episode of similar pain last week that resolved spontaneously. His BP is 145/75 mm Hg, HR is 90 beats/minute, RR is 24 breaths/minute, and temperature is 98.9°F. As you examine the patient, he vomits and has trouble lying still in his stretcher. His abdomen is soft and nontender. Which of the following is the most appropriate next step in management? A. Call surgery consult to evaluate the patient for appendicitis B. Order an abdominal CT C. Start intravenous (IV) fluids and administer an IV nonsteroidal anti-inflammatory drug (NSAID) and antiemetic D. Perform an ultrasound to evaluate for an abdominal aortic aneurysm (AAA) E. Perform an ultrasound to evaluate for testicular torsiom
Answer: C Explanation: *The patient's history of colicky flank pain that radiates to the groin and hematuria is consistent with a ureteral stone.* Adequate analgesia is critical in treating a patient with a ureteral stone. Intravenous ketorolac (a NSAID), is frequently administered as a first-line analgesic, but morphine or other opioids may be necessary for continued pain. In addition to analgesics, antiemetics are often administered for nausea and vomiting.
A 57-year-old woman presents to the ED with several hours of abdominal pain and vomiting. You examine her abdomen and note that it is distended and there is a small midline scar in the lower abdomen. Upon auscultation, you hear high-pitched "tinkling" bowel sounds. Palpation elicits pain in all four quadrants but no rebound tenderness. She is guaiac negative. Which of the following is the most likely to be responsible for this patient's symptoms? A. Travel to Mexico B. Ethanol abuse C. Previous hysterectomy D. Constipation
Answer: C Explanation: The patient presentation is suggestive of a SBO. Symptoms of SBO include colicky abdominal pain, vomiting, abdominal distention, hyperactive bowel sounds, and decreased flatus. *The most common cause of SBO is postoperative adhesions, responsible for more than 50% of all SBO.* One of the more common procedures associate with SBO is a hysterectomy. Other common causes of SBO include hernia and neoplasm.
An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing home with a note from the facility stating that she was complaining of abdominal pain and vomited once. Her vital signs in the ED are blood pressure (BP) 105/75 mm Hg, heart rate (HR) 95 beats/minute, respiratory rate (RR) 18 breaths/minute, and temperature 100.1°F. The patient appears very uncomfortable and has not stopped moaning in pain since arriving to the ED. You are surprised to find that her abdomen is soft and nontender on palpation. Which of the following diagnostic tests is most likely to reveal the cause of her symptoms? A. Capsule endoscopy B. Colonoscopy C. CT angiography of the abdomen D. Ultrasound E. Abdominal radiograph
Answer: C Explanation: This patient has mesenteric ischemia secondary to a thromboembolism from atrial fibrillation. *The classic presentation of acute mesenteric ischemia is sudden onset of poorly localized abdominal pain in an individual with underlying cardiac disease. Arterial emboli are the most common cause of acute mesenteric ischemia, responsible for approximately 50% of cases.* Most emboli are cardiac in origin, arising from mural thrombi or valvular lesions. Atrial fibrillation is an important risk factor for mesenteric ischemia owing to the propensity to form mural thrombi. Mesenteric ischemia can also occur as a result of thrombosis within mesenteric arteries, typically seen in patients with advanced atherosclerotic disease. *Physical examination findings are notable for "pain out of proportion to examination" where a patient may be writhing from abdominal pain but have a soft, nontender abdomen.* While mesenteric angiography remains the gold standard for diagnosis of acute mesenteric ischemia, CT angiography has largely supplanted traditional angiography and is the initial test of choice for mesenteric ischemia. Vascular surgery should be consulted emergently if mesenteric ischemia is suspected.
A 78-year-old woman is brought to the ED by EMS with vomiting and abdominal pain that began during the night. Her BP is 90/50 mm Hg, HR is 110 beats/minute, RR is 18 breaths/minute, and temperature is 101.2°F. She appears jaundiced. She winces when you palpate her RUQ. An ultrasound reveals dilation of the common bile duct and stones in the gallbladder. What is the most likely diagnosis? A. Cholecystitis B. Acute hepatitis C. Cholangitis D. Pancreatic cancer E. Bowel obstruction
Answer: C Explanation: The patient's clinical picture is consistent with ascending cholangitis, a bacterial infection of the biliary tree caused by biliary tract obstruction. Obstruction may occur as a result of gallstones, stricture, or malignancy. *The classic "Charcot triad" of ascending cholangitis is RUQ pain, fever, and jaundice.* Cholangitis is a surgical emergency and patients can rapidly become septic. Ultrasound may demonstrate intrahepatic or ductal dilation. The presence of stones in the gallbladder suggests gallstones as the etiology of obstruction.
A 28-year-old man presents to the ED complaining of constant, vague, diffuse abdominal pain. He reports decreased appetite and nausea since eating sushi last night. His BP is 125/75 mm Hg, HR is 96 beats/minute, RR is 16 breaths/minute, and temperature is 100.5°F. On examination, his abdomen is moderately tender in the right-lower quadrant (RLQ). Palpation of the left-lower quadrant (LLQ) elicits pain in the RLQ. Laboratory results reveal a WBC of 12,000/μL. Urinalysis shows 1+ leukocyte esterase. The patient is convinced that his symptoms are due to food poisoning from the sushi and is requesting an antacid. Which of the following is the most appropriate next step in management? A. Order a plain radiograph to look for dilated bowel loops B. Administer Maalox and observe for 1 hour C. Send the patient for an abdominal ultrasound D. Order an abdominal CT scan E. Discharge the patient home with ciprofloxacin
Answer: D Explanation: *Appendicitis is the most common cause of the acute surgical abdomen. The classic presentation is the onset of dull periumbilical pain, which eventually migrates to the RLQ.* Associated symptoms include anorexia, nausea, and vomiting. Low-grade fever may be present. Rovsing sign refers to the elicitation of pain in the RLQ when the LLQ is palpated. Leukocytosis is often present, but a normal WBC count does not rule out appendicitis. Urinalysis may show pyuria if the inflamed appendix results in ureteral irritation. Abdominal CT with IV and oral or rectal contrast is the test of choice in adults, with a reported sensitivity of up to 100% and specificity of 95%. CT findings of appendicitis include an enlarged appendix (> 6 mm), pericecal inflammation, and the presence of an appendicolith.
A 15-year-old boy complains of sharp, radiating left testicular pain, which started while playing basketball 1 hour ago. He denies specific trauma, but tells you he first noted the pain while running. He also says that he was recently treated for epididymitis "with two antibiotics" but admits that he did not finish them. Physical examination reveals a tender, slightly enlarged left testicle lying in the horizontal plane. There is no cremasteric reflex on the left, but it is present on the right. When you look at his scrotum, you do not see a "blue dot" sign. Your next step is to: A. Place him in the supine position, administer parenteral analgesics, and observe for changes. B. Hospitalize him for treatment with intravenous antibiotics. C. Counsel him on the importance of taking medications as prescribed and discharge him with scrotal elevation and oral antibiotics. D. Consult urology and obtain consent for surgery.
Answer: D Explanation: Although torsion may occur at any age, it is most common in the first year of life and at puberty. It is more common in undescended testis and should be considered in a patient with a painful inguinal mass and an empty scrotum. The onset is usually acute and frequently follows physical activity. The initial effect of torsion is venous engorgement, which leads to edema, pain, and tenderness. Depending on the extent of vascular compromise, it can progress to necrosis and infarction and attempts at detorsion should be made as soon as possible. *Emergent urologic consultation should be obtained and manual detorsion can be attempted after appropriate analgesia. Even if successful, the patient still requires definitive surgical care. In cases where the diagnosis is in doubt, a testicular ultrasound with color Doppler flow is the test of choice at most institutions.*
A 29-year-old male is brought in by EMS after being found by a friend stuporous in his apartment. His friend tells you that the patient is a migrant construction worker from Mexico and had not shown up for work for the past 5 days. As far as the friend knows, the patient has no medical problems and does not use drugs or alcohol. He is unsure about the patient's family medical history. EMS reports that the patient's glucose was "high" (>600). His vital signs reveal hypotension and tachycardia. On exam, the patient is stuporous, has dry mucous membranes, clear lung fields, and poor skin turgor. His abdomen is soft and nontender. The patient receives two large bore IVs and 2 L of normal saline (NS). His vital signs remain normal and the patient is able to answer simple questions. On neurological exam, the patient has profound weakness in his upper and lower extremities. Which of the following electrolyte abnormalities pose the most immediate risk for bad outcome in this patient? A. Chloride B. Glucose C. Magnesium D. Potassium
Answer: D Explanation: This patient is likely suffering from a hyperosmolar hyperglycemic state (HHS). His glucose is greater than 600 mg/dL. While all of the labs are helpful, the most important electrolyte abnormality is hypokalemia and should be anticipated. *As treatment of HHS with fluids and insulin often alter the serum potassium levels, the importance of monitoring of serum potassium levels and repletion cannot be overemphasized.* Serum sodium is often abnormal in patients with HHS. They often have low sodium levels. In severe hyperglycemia, the sodium must be corrected for with the formula: corrected [Na] = measured [Na] + [1.6 × (glucose − 100)]/100.
A 54 year-old man comes to the urgent care because he was awoken suddenly from his sleep this morning with severe left flank pain radiating to his left testicle with associated nausea and vomiting. He is afebrile and vital signs are normal. He is constantly moving to find a comfortable position. On physical examination, left flank tenderness is noted with no direct testicular tenderness. Urinalysis reveals a pH of 5.5 and microscopic hematuria, but is otherwise unremarkable. Which of the following is the most likely diagnosis? A. Acute epididymitis B. Appendicitis C. Diverticulitis D. Nephrolithiasis
Answer: D Explanation: *Nephrolithiasis usually presents as a sudden onset of colicky flank pain with associated nausea and vomiting.* Urinalysis often reveals gross or microscopic hematuria. Diverticulitis presents with left lower quadrant pain that does not radiate to the testicle. The patient would not have hematuria. Appendicitis is associated with fever, abdominal pain and peritoneal signs. Acute epididymitis is characterized by symptoms of cystitis or urethritis (urethral discharge, pain at the tip of the penis) with pain in the scrotum that may radiate to the flank.
A tall, thin 18-year-old man presents to the ED with acute onset of dyspnea while at rest. The patient reports sitting at his desk when he felt a sharp pain on the right side of his chest that worsened with inspiration. His past medical history is significant for peptic ulcer disease. He reports taking a 2-hour plane trip a month ago. His initial vitals include a BP of 120/60 mm Hg, HR of 100 beats/minute, RR of 16 breaths/minute, and an oxygen saturation of 97% on room air. On physical examination, you note decreased breath sounds on the right side. Which of the following tests should be performed next? A. Electrocardiogram (ECG) B. d-dimer C. Ventilation perfusion scan (V/Q scan) D. Upright abdominal radiograph E. Chest radiograph
Answer: E Explanation: *A spontaneous pneumothorax typically presents with ipsilateral pleuritic chest pain and dyspnea while at rest. Mild tachycardia, decreased breath sounds to auscultation, or hyperresonance to percussion are the most common findings.* It typically occurs in healthy young men of taller than average stature without a precipitating factor. Mitral valve prolapse and Marfan syndrome are also associated with pneumothoraces. The most common condition associated with secondary spontaneous pneumothorax is chronic obstructive pulmonary disease (COPD). Although suggested by this patient's symptoms, the diagnosis of pneumothorax is generally made with a chest radiograph. The classic radiograph finding is the appearance of a thin, visceral, pleural line lying parallel to the chest wall, separated by a radiolucent band that is devoid of lung markings as shown in the figure below. The diagnosis can also be seen on point-of-care ultrasound by the absence of lung sliding. If clinical suspicion is high with a negative initial chest x-ray, inspiratory and expiratory films, or a lateral decubitus film may be taken to evaluate for lung collapse.
A 37-year-old male presents to the ED with altered mental status. He was found unconscious in the bathroom at work. On exam, he is arousable to painful stimulus, muttering incoherently. His airway is intact and he has bilateral breath sounds. His initial vital signs are blood pressure (BP) 95/47, P 110, respiratory rate (RR) 14, O2% 97% on room air, T 99.4. He has dry mucus membranes. Fingerstick glucose is 396. Lab work reveals a normal CBC, 3+ acetone, Na 121, Cl- 97, HCO3 9, K 3.0, Mg 2.9, Phos 1.5, AG 29. Which of the following is the first priority in caring for this patient? A. IV bicarbonate B. IV lactated ringers C. IV phosphate D. IV potassium E. IV saline
Answer: E Explanation: In patients with diabetes mellitus, it is very important to prioritize therapeutic interventions. *The order of therapeutic priorities is volume resuscitation first and foremost.* Patients often have a fluid deficit of 5-10 L. Potassium deficits should be addressed next. Diabetic ketoacidosis (DKA) patients often have profound total-body potassium deficits. For an initial potassium level between 3.3 and 5.3 mEq/L, with established urine output, potassium should be replaced at a rate of 10 mEq KCL per hour for 4 hours. Insulin may be given, but only after volume resuscitation and potassium deficits have been addressed. It may be administered at a bolus of 0.1 units/kg and followed by a drip of 0.1 units/kg per hour.
A 58-year-old obese female presents with abdominal pain localized to the left lower quadrant. A CT scan of the abdomen and pelvis reveals sigmoid diverticulitis with mesenteric abscess measuring 5 cm. Appropriate disposition of this patient is: A. Discharge home with PO antibiotics for 2 weeks B. Discharge home with PO antibiotics for 2 weeks with a 48-hour recheck C. Discharge home after surgery consultation with PO antibiotics D. Admit for 24-hour observation E. Admit for IV antibiotics and surgery consultation.
Answer: E Explanation: The majority of uncomplicated diverticulitis improves with bowel rest (liquid diet) and antibiotics. It is estimated that conservative treatment in this group of patients has a 70-100% success rate. In cases where uncomplicated diverticulitis is confirmed with CT, the success rate is 97%. Most patients should be able to follow this regimen as an outpatient. *Complicated diverticulitis (perforation, abscess, obstruction, fistula) generally requires admission.* In addition to the standard regimen of bowel rest and IV antibiotics, patients will need specific treatments directed at the complications.
A 74-year-old woman with a history of congestive heart failure presents with diffuse abdominal pain that started 2 hours ago. She describes the pain as severe and she is in significant distress secondary to pain. She has a temperature of 100.5, a heart rate of 110, and a blood pressure of 95/60 mm Hg. Her cardiovascular exam is remarkable for an irregular heart beat. She has a distended abdomen with hypoactive bowel sounds and diffuse tenderness to palpation on abdominal exam. There is no focal tenderness, rebound, or guarding. On rectal examination, there is profuse soft, dark brown stool that is guaiac positive. Lab results are remarkable for WBC of 16 and a lactic acid of 4.0. After fluid resuscitation and antibiotics, what is the MOST appropriate next step in the management of this patient? A. CT scan of the abdomen B. GI consult for endoscopy C. Medical admission for observation D. Right upper quadrant ultrasound E. Surgical consult
Answer: E Explanation: The most likely diagnosis is mesenteric ischemia secondary to low arterial flow or thromboembolism given the history of congestive heart failure, clinical findings consistent with atrial fibrillation, and pain out of proportion to exam. *Mesenteric ischemia is a surgical emergency that will often lead to bowel necrosis and overwhelming sepsis if left untreated.* Despite aggressive treatment, prognosis is poor with a survival of 50% if diagnosed within 24 hours. Immediate surgical consultation is required as soon as the diagnosis is suspected to increase the patient's chance of survival. CT scan of the abdomen should be obtained after surgical consultation, but should not delay taking the patient to the operating room.
A 24-year-old woman is brought to the ED after being found on a nearby street hunched over and in mild respiratory distress. Upon arrival, she is tachypneic at 28 breaths/minute with an oxygen saturation of 97% on facemask oxygen administration. On physical examination, the patient appears to be in mild distress with supraclavicular retractions. Scattered wheezing is heard throughout bilateral lung fields. Which of the following medications should be administered first? A. Corticosteroids B. Magnesium sulfate C. Epinephrine D. Anticholinergic nebulizer treatment E. β2-agonist nebulizer treatment
Answer: E Explanation: This patient is suffering from an acute asthma exacerbation. This is reversible bronchospasm initiated by a variety of environmental factors that produce a narrowing and inflammation of the bronchial airways. *The first-line treatment in order to open the airways includes a aerosolized β2-agonist, which acts to decrease bronchospasm of the smooth muscle.*
Which of the following diagnostic studies is indicated in the evaluation of an upper gastrointestinal bleed? A. Esophageal manometry B. Bleeding scan C. Upper endoscopy D. Barium swallow
C. Upper endoscopy Explanation: *Endoscopy is the evaluation modality of choice in patients with upper GI bleeding.* The advantage of this technique is that it can be used for both diagnostic and therapeutic purposes. Esophageal manometry is not indicated in the evaluation of upper gastrointestinal bleeding. Bleeding scans are most useful to evaluate occult GI bleeding. Radioactive isotope tracing is useful to concentrate bleeding sites at a single location. It is most useful to find bleeding that is occurring in the large or small bowel rather than in the upper GI sites. Barium swallow is not indicated in the evaluation of upper gastrointestinal bleeding.
An 18-year-old male presents with abdominal pain that began approximately 8 hours ago. Initially, he experienced nausea with periumbilical pain that is now primarily in the right lower quadrant. He has never been hospitalized or had any surgeries. On exam, his temperature is 100.6°F, and his abdominal exam reveals tenderness at McBurney's point. Based on the most likely diagnosis, what should be the next BEST step? A. CBC and urinalysis B. CT scan of the abdomen/pelvis C. Plain films of the abdomen D. Surgical consultation E. Ultrasound of the abdomen
Answer: D Explanation: Surgical consultation is recommended for any patient with a classic history for appendicitis. However, some surgeons may request imaging (CT scan of abdomen/pelvis) before they will take the patient to the operating room.
A 41-year-old homeless man walks into the ED complaining of abdominal pain, nausea, and vomiting. He tells you that he has been drinking beer continuously over the previous 18 hours. On examination, his vitals are BP 150/75 mm Hg, HR 104 beats/minute, RR 16 breaths/minute, temperature 99.1°F, and oxygen saturation 97% on room air. A finger stick glucose is 81 mg/dL. The patient is alert and oriented and his pupils are anicteric. You notice gynecomastia and spider angiomata. His abdomen is soft but tender in the RUQ. Laboratory tests reveal an AST of 212 U/L, ALT of 170 U/L, alkaline phosphatase of 98 U/L, total bilirubin of 1.9 mg/dL, international normalized ratio (INR) of 1.3, and WBC of 12,000/μL. Urinalysis shows 1+ protein. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management? A. Place a nasogastric (NG) tube in the patient's stomach to remove any remaining ethanol B. Order a HIDA scan to evaluate for acute cholecystitis C. Administer hepatitis B immune globulin D. Send viral hepatitis titers E. Provide supportive care by correcting any fluid and electrolyte imbalances
Answer: E Explanation: The patient's clinical presentation is consistent with alcoholic hepatitis, which is a potentially severe form of alcohol-induced liver disease. The presentation can range from nausea and vomiting to fulminant hepatitis and liver failure. Laboratory tests may reveal moderate elevations of AST and ALT. *In alcoholic hepatitis, the AST is usually greater than ALT (think "scotch" and "tonic" for AST > ALT).* The patient may exhibit stigmata of chronic liver disease such as gynecomastia and spider angiomata. The management of alcoholic liver disease is supportive, with fluid hydration and correction of electrolyte imbalances, paying special attention to blood glucose (ethanol can suppress gluconeogenesis) and magnesium. Thiamine should also be administered to prevent Wernicke encephalopathy.
