Diverticular disease US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Diverticular disease. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Diverticular disease US Medical PG Question 1: A 62-year-old man presents to the emergency department with acute pain in the left lower abdomen and profuse rectal bleeding. These symptoms started 3 hours ago. The patient has chronic constipation and bloating, for which he takes lactulose. His family history is negative for gastrointestinal disorders. His temperature is 38.2°C (100.8°F), blood pressure is 90/60 mm Hg, and pulse is 110/min. On physical examination, the patient appears drowsy, and there is tenderness with guarding in the left lower abdominal quadrant. Flexible sigmoidoscopy shows multiple, scattered diverticula with acute mucosal inflammation in the sigmoid colon. Which of the following is the best initial treatment for this patient?
- A. Elective colectomy
- B. Dietary modification and antibiotics
- C. Volume replacement, analgesia, intravenous antibiotics, and endoscopic hemostasis
- D. Volume replacement, analgesia, intravenous antibiotics, and surgical hemostasis (Correct Answer)
- E. Reassurance and no treatment is required
Diverticular disease Explanation: ***Volume replacement, analgesia, intravenous antibiotics, and surgical hemostasis***
- This patient presents with **acute complicated diverticulitis** with signs of **peritonitis** (left lower abdominal pain with guarding) and **septic shock** (fever 38.2°C, hypotension 90/60 mm Hg, tachycardia 110/min, drowsiness).
- Initial management requires **volume replacement** to address hypovolemia and shock, **analgesia** for pain control, and **broad-spectrum intravenous antibiotics** covering gram-negative and anaerobic organisms.
- The presence of **peritonitis with hemodynamic instability** indicates complicated diverticulitis requiring **surgical intervention** (typically sigmoid resection with colostomy - Hartmann procedure) after initial resuscitation.
- While the patient has rectal bleeding, the dominant clinical picture is **perforation/transmural inflammation** requiring surgery, not just bleeding control.
*Volume replacement, analgesia, intravenous antibiotics, and endoscopic hemostasis*
- **Endoscopic hemostasis** is appropriate for uncomplicated diverticular bleeding without signs of perforation or peritonitis.
- In this case, the patient has **guarding** (indicating peritonitis) and **septic shock**, suggesting transmural inflammation or perforation that cannot be managed endoscopically.
- Endoscopy is relatively contraindicated in acute diverticulitis with peritonitis due to risk of worsening perforation.
*Elective colectomy*
- While colectomy is the correct surgical approach, the term **"elective"** is inappropriate for this acute, life-threatening emergency.
- This patient requires **urgent/emergency surgery** after initial resuscitation, not scheduled elective surgery.
*Dietary modification and antibiotics*
- **Dietary modification** (high-fiber diet) is a preventive strategy for uncomplicated diverticular disease, not treatment for acute complicated diverticulitis.
- While antibiotics are necessary, this option fails to address the **septic shock, hypovolemia, and need for surgical intervention** in complicated diverticulitis with peritonitis.
*Reassurance and no treatment is required*
- The patient exhibits **life-threatening complications**: septic shock, peritonitis, and hemodynamic instability.
- **No treatment** would result in rapid deterioration, multi-organ failure, and death.
Diverticular disease US Medical PG Question 2: A 75-year-old man presents to the emergency department for abdominal pain. The patient states the pain started this morning and has been worsening steadily. He decided to come to the emergency department when he began vomiting. The patient has a past medical history of obesity, diabetes, alcohol abuse, and hypertension. His current medications include captopril, insulin, metformin, sodium docusate, and ibuprofen. His temperature is 104.0°F (40°C), blood pressure is 160/97 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Abdominal exam reveals left lower quadrant tenderness. Cardiac exam reveals a crescendo systolic murmur heard best by the right upper sternal border. Lab values are ordered and return as below.
Hemoglobin: 15 g/dL
Hematocrit: 42%
Leukocyte count: 19,500 cells/mm^3 with normal differential
Platelet count: 226,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 101 mEq/L
K+: 4.4 mEq/L
HCO3-: 24 mEq/L
BUN: 22 mg/dL
Glucose: 144 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 9.8 mg/dL
Which of the following is the most accurate test for this patient's condition?
- A. Colonoscopy
- B. Sigmoidoscopy
- C. Amylase and lipase levels
- D. Barium enema
- E. CT scan (Correct Answer)
Diverticular disease Explanation: ***CT scan***
- The patient presents with classic symptoms of **diverticulitis**, including **left lower quadrant pain**, **fever**, and **leukocytosis**. A **CT scan with oral and IV contrast** is the most accurate diagnostic test to identify diverticular inflammation, abscess formation, or perforation.
- A CT scan can also help rule out other causes of abdominal pain and guide further management, such as the need for percutaneous drainage of an abscess.
*Colonoscopy*
- **Colonoscopy is contraindicated during an acute episode of diverticulitis** due to the risk of **perforation** of an inflamed colon.
- It may be considered **6-8 weeks after resolution of acute diverticulitis** to investigate for other pathologies such as malignancy.
*Sigmoidoscopy*
- Similar to colonoscopy, **sigmoidoscopy is generally avoided in acute diverticulitis** because of the risk of **perforation** of the inflamed bowel from instrumentation.
- Its diagnostic yield in acute settings is also limited compared to CT imaging.
*Amylase and lipase levels*
- These tests are primarily used to diagnose **pancreatitis**, which typically presents with **epigastric pain radiating to the back**, often associated with elevated enzyme levels.
- While vomiting is present, the **left lower quadrant tenderness and fever** point away from pancreatitis as the primary diagnosis.
*Barium enema*
- **Barium enema is generally contraindicated in acute diverticulitis** due to the risk of **perforation** and the introduction of barium into the peritoneum, which can cause severe peritonitis.
- It has largely been replaced by **CT scanning** for its superior safety profile and diagnostic accuracy in acute abdominal conditions.
Diverticular disease US Medical PG Question 3: A 24-year-old man presents to the emergency department for severe abdominal pain for the past day. The patient states he has had profuse, watery diarrhea and abdominal pain that is keeping him up at night. The patient also claims that he sees blood on the toilet paper when he wipes and endorses having lost 5 pounds recently. The patient's past medical history is notable for IV drug abuse and a recent hospitalization for sepsis. His temperature is 99.5°F (37.5°C), blood pressure is 120/68 mmHg, pulse is 100/min, respirations are 14/min, and oxygen saturation is 98% on room air. On physical exam, you note a young man clutching his abdomen in pain. Abdominal exam demonstrates hyperactive bowel sounds and diffuse abdominal tenderness. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?
- A. Vancomycin (Correct Answer)
- B. Mesalamine enema
- C. Metronidazole
- D. Clindamycin
- E. Supportive therapy and ciprofloxacin if symptoms persist
Diverticular disease Explanation: ***Vancomycin***
- The patient's history of **IV drug abuse**, recent **hospitalization for sepsis**, and severe abdominal symptoms with **bloody diarrhea** and **weight loss** are highly suggestive of **Clostridioides difficile infection (CDI)**.
- **Oral vancomycin** is the recommended first-line treatment for **severe C. difficile infection**, especially with signs like systemic illness (tachycardia) and marked abdominal tenderness.
*Mesalamine enema*
- **Mesalamine** is an **anti-inflammatory drug** primarily used for **mild to moderate ulcerative colitis**, particularly when the disease is limited to the rectum or rectosigmoid colon.
- While inflammatory bowel disease can cause bloody diarrhea, the acute presentation with recent hospitalization and IV drug use makes **infectious etiologies**, particularly CDI, much more likely.
*Metronidazole*
- **Metronidazole** is an antibiotic that was previously used for uncomplicated **C. difficile infection**.
- However, **oral vancomycin** is now preferred for **initial CDI episodes** due to superior efficacy, especially in severe cases, and metronidazole is generally reserved for non-severe cases if vancomycin is unavailable or not tolerated.
*Clindamycin*
- **Clindamycin** is an antibiotic notorious for being a common cause of **antibiotic-associated C. difficile infection**.
- Giving clindamycin in this scenario would likely **worsen the patient's condition** if C. difficile is indeed the cause, as it promotes C. difficile overgrowth.
*Supportive therapy and ciprofloxacin if symptoms persist*
- While **supportive care** (hydration, electrolyte management) is essential, it is **insufficient as the sole treatment** for severe C. difficile infection.
- **Ciprofloxacin** is an antibiotic that is **ineffective against C. difficile** and could potentially exacerbate the infection by disrupting the normal gut microbiota.
Diverticular disease US Medical PG Question 4: Please refer to the summary above to answer this question
Which of the following is the most likely diagnosis?
Patient information
Age: 61 years
Gender: F, self-identified
Ethnicity: unspecified
Site of care: emergency department
History
Reason for Visit/Chief Concern: "My belly really hurts."
History of Present Illness:
developed abdominal pain 12 hours ago
pain constant; rated at 7/10
has nausea and has vomited twice
has had two episodes of nonbloody diarrhea in the last 4 hours
12-month history of intermittent constipation
reports no sick contacts or history of recent travel
Past medical history:
hypertension
type 2 diabetes mellitus
mild intermittent asthma
allergic rhinitis
Social history:
diet consists mostly of high-fat foods
does not smoke
drinks 1–2 glasses of wine per week
does not use illicit drugs
Medications:
lisinopril, metformin, albuterol inhaler, fexofenadine, psyllium husk fiber
Allergies:
no known drug allergies
Physical Examination
Temp Pulse Resp. BP O2 Sat Ht Wt BMI
38.4°C
(101.1°F)
85/min 16/min 134/85 mm Hg –
163 cm
(5 ft 4 in)
94 kg
(207 lb)
35 kg/m2
Appearance: lying back in a hospital bed; appears uncomfortable
Neck: no jugular venous distention
Pulmonary: clear to auscultation; no wheezes, rales, or rhonchi
Cardiac: regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops
Abdominal: obese; soft; tender to palpation in the left lower quadrant; no guarding or rebound tenderness; normal bowel sounds
Extremities: no edema; warm and well-perfused
Skin: no rashes; dry
Neurologic: alert and oriented; cranial nerves grossly intact; no focal neurologic deficits
- A. Cholecystitis
- B. Crohn disease
- C. Diverticulitis (Correct Answer)
- D. Appendicitis
- E. Irritable bowel syndrome
Diverticular disease Explanation: ***Diverticulitis***
- The patient's presentation of acute **left lower quadrant abdominal pain**, fever (38.4°C), nausea, vomiting, and a history of intermittent constipation is highly suggestive of diverticulitis.
- Her obesity (BMI 35 kg/m2) and diet consisting mostly of high-fat foods are also **risk factors** for diverticular disease.
*Cholecystitis*
- This condition typically causes acute pain in the **right upper quadrant** of the abdomen, sometimes radiating to the right shoulder, which is inconsistent with the patient's left lower quadrant pain.
- While nausea and vomiting can occur, the localization of pain is a key differentiator.
*Crohn disease*
- Crohn disease usually presents with **chronic abdominal pain**, weight loss, fatigue, and persistent diarrhea, often with blood.
- The acute, localized pain with fever and recent constipation followed by non-bloody diarrhea does not fit the typical presentation of an acute flare of Crohn disease, though it can occur anywhere in the GI tract.
*Appendicitis*
- Acute appendicitis almost universally presents with pain that localizes to the **right lower quadrant** (McBurney's point), initially periumbilical.
- The patient's pain is clearly localized to the left lower quadrant, ruling out appendicitis.
*Irritable bowel syndrome*
- While IBS can cause recurrent abdominal pain, constipation, and diarrhea, it is a **functional disorder** and does not typically involve fever or a localized, acute inflammatory process as seen in this patient.
- The acute presentation with fever and severe, localized pain points away from IBS.
Diverticular disease US Medical PG Question 5: A 68-year-old female presents to your office for her annual check-up. Her vitals are HR 85, T 98.8 F, RR 16, BP 125/70. She has a history of smoking 1 pack a day for 35 years, but states she quit five years ago. She had her last pap smear at age 64 and states all of her pap smears have been normal. She had her last colonoscopy at age 62, which was also normal. Which of the following is the next best test for this patient?
- A. Pap smear
- B. Chest radiograph
- C. Abdominal ultrasound
- D. Colonoscopy
- E. Chest CT scan (Correct Answer)
Diverticular disease Explanation: ***Chest CT scan***
- This patient is a 68-year-old female with a **35-pack-year smoking history** who quit 5 years ago, placing her in a high-risk group for lung cancer.
- **Low-dose computed tomography (LDCT)** for lung cancer screening is recommended annually for individuals aged 50-80 with a 20-pack-year smoking history who currently smoke or have quit within the past 15 years.
*Pap smear*
- A Pap smear is not indicated as she had her last one at age 64 and all previous results were normal.
- Guidelines recommend discontinuing Pap smears at age 65 if there is no history of moderate or severe dysplasia and three consecutive negative results within the last 10 years.
*Chest radiograph*
- A chest radiograph is a less sensitive and specific tool for detecting early lung cancer compared to LDCT.
- It misses a significant proportion of early-stage lung cancers and is not recommended for lung cancer screening.
*Abdominal ultrasound*
- An abdominal ultrasound is generally used to screen for conditions like abdominal aortic aneurysm in specific high-risk populations (males 65-75 who have ever smoked).
- There is no indication from the provided history for an abdominal ultrasound in this patient.
*Colonoscopy*
- This patient had a normal colonoscopy at age 62.
- Current guidelines recommend repeating colonoscopy every 10 years if the previous one was normal, so she is not due for another one yet.
Diverticular disease US Medical PG Question 6: A 65-year-old man presents to his primary care physician for a yearly checkup. He states he feels he has been in good health other than minor fatigue, which he attributes to aging. The patient has a past medical history of hypertension and is currently taking chlorthalidone. He drinks 1 glass of red wine every night. He has lost 5 pounds since his last appointment 4 months ago. His temperature is 99.2°F (37.3°C), blood pressure is 147/98 mmHg, pulse is 80/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals an obese man in no acute distress. Laboratory values are ordered as seen below.
Hemoglobin: 9 g/dL
Hematocrit: 27%
Mean corpuscular volume: 72 µm^3
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 193,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 101 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 9.0 mg/dL
AST: 32 U/L
ALT: 20 U/L
25-OH vitamin D: 15 ng/mL
Which of the following is the best next step in management?
- A. Counseling for alcohol cessation
- B. Vitamin D supplementation
- C. Colonoscopy (Correct Answer)
- D. Exercise regimen and weight loss
- E. Iron supplementation
Diverticular disease Explanation: ***Colonoscopy***
- The patient presents with **microcytic anemia** (hemoglobin 9 g/dL, MCV 72 µm^3) and **unexplained weight loss** in an elderly male, which is highly suggestive of **gastrointestinal bleeding**, often due to **colorectal cancer**.
- A **colonoscopy** is the definitive diagnostic and therapeutic procedure for evaluating the lower gastrointestinal tract for sources of bleeding and identifying/removing suspicious lesions.
*Counseling for alcohol cessation*
- While chronic alcohol use can contribute to various health issues, including some anemias (e.g., folate deficiency), the patient's presented **microcytic anemia** is not typical for alcohol-related causes.
- The patient's reported alcohol intake of one glass of red wine nightly is generally considered moderate and less likely to be the primary cause of his symptoms and lab findings.
*Vitamin D supplementation*
- The patient has a **low 25-OH vitamin D level (15 ng/mL)**. However, this finding, while important for bone health and overall well-being, does not explain his microcytic anemia or unexplained weight loss.
- Addressing the **anemia and weight loss** takes precedence as these symptoms point to a more urgent, potentially life-threatening condition.
*Exercise regimen and weight loss*
- The patient is obese and has hypertension, for which an **exercise regimen and weight loss** would be beneficial for overall health and blood pressure management.
- However, these interventions **do not address the microcytic anemia and unexplained weight loss**, which are more pressing concerns requiring immediate investigation.
*Iron supplementation*
- The **microcytic anemia** strongly suggests **iron deficiency**, and iron supplementation would eventually be part of treatment.
- However, **iron supplementation** without identifying and treating the underlying cause of iron loss (e.g., gastrointestinal bleeding) would be insufficient and could delay a crucial diagnosis.
Diverticular disease US Medical PG Question 7: A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1–2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Which of the following is the most appropriate next step in management?
- A. D-xylose absorption test
- B. CT scan of the abdomen and pelvis with contrast
- C. Capsule endoscopy
- D. Colonoscopy (Correct Answer)
- E. Flexible sigmoidoscopy
Diverticular disease Explanation: ***Colonoscopy***
- The patient presents with **bloody diarrhea** and **lower abdominal pain**, which are classic symptoms of inflammatory bowel disease (IBD), particularly **Crohn's disease** or **ulcerative colitis**. A colonoscopy allows for direct visualization of the colonic and terminal ileal mucosa, **biopsy collection** for histological confirmation, and assessment of disease extent and severity.
- While the patient's hemoglobin is currently normal, the presence of bloody stools indicates potential ongoing blood loss, and the history of fatigue suggests chronic inflammation. **Colonoscopy is the gold standard** for diagnosing and differentiating types of IBD.
*D-xylose absorption test*
- This test is used to assess **small bowel mucosal function** and carbohydrate absorption, typically in cases of suspected malabsorption like **celiac disease**.
- While malabsorption can cause fatigue, the patient's primary symptoms of bloody diarrhea and abdominal pain are not typical for isolated malabsorption, and a d-xylose test would not identify the source of bleeding.
*CT scan of the abdomen and pelvis with contrast*
- A CT scan can identify **extraintestinal manifestations** of IBD, abscesses, or bowel wall thickening, but it is **less sensitive** than colonoscopy for direct mucosal evaluation and cannot obtain biopsies for definitive diagnosis.
- It might be considered after colonoscopy for assessing transmural involvement or complications but is not the initial diagnostic step for primary luminal symptoms.
*Capsule endoscopy*
- Capsule endoscopy is primarily used to evaluate the **small bowel** for lesions beyond the reach of standard upper endoscopy and colonoscopy, such as obscure GI bleeding or suspected Crohn's disease confined to the small bowel.
- Given the patient's symptoms of **lower abdominal pain** and bloody diarrhea, the pathology is likely in the colon or terminal ileum, making colonoscopy more appropriate for initial evaluation. A capsule endoscopy does not visualize the colon.
*Flexible sigmoidoscopy*
- A flexible sigmoidoscopy visualizes the **rectum and a portion of the sigmoid colon**, which might be affected in ulcerative colitis.
- However, it would miss lesions in the more proximal colon or terminal ileum, which are common sites for Crohn's disease and some forms of ulcerative colitis, thus potentially leading to an incomplete diagnosis.
Diverticular disease US Medical PG Question 8: Three days after admission to the hospital with a clinical diagnosis of ischemic colitis, a 65-year-old man has recovered from his initial symptoms of bloody diarrhea and abdominal pain with tenderness. He feels well at this point and wishes to go home. He has a 15-year history of diabetes mellitus. Currently, he receives nothing by mouth, and he is on IV fluids, antibiotics, and insulin. His temperature is 36.7°C (98.1°F), pulse is 68/min, respiratory rate is 13/min, and blood pressure is 115/70 mm Hg. Physical examination of the abdomen shows no abnormalities. His most recent laboratory studies are all within normal limits, including glucose. Which of the following is the most appropriate next step in management?
- A. Laparoscopy
- B. Discharge home with follow-up in one month
- C. Laparotomy
- D. Total parenteral nutrition
- E. Colonoscopy (Correct Answer)
Diverticular disease Explanation: ***Colonoscopy***
- A colonoscopy is crucial for **evaluating the extent of ischemic damage**, identifying strictures, and ruling out other pathologies like inflammatory bowel disease or malignancy.
- While the patient is clinically stable, direct visualization of the colonic mucosa a few days after the acute event is necessary to **assess healing** and guide future management.
*Laparoscopy*
- **Laparoscopy is an invasive surgical procedure** primarily used for diagnosis and intervention in acute abdominal conditions, which are not present here.
- Given the patient's stable condition and resolution of symptoms, a less invasive diagnostic tool like colonoscopy is more appropriate at this stage.
*Discharge home with follow-up in one month*
- Discharging the patient without further investigation is **premature** as the full extent of the ischemic injury and potential long-term complications are unknown.
- There is a risk of **stricture formation** or recurrent ischemia, necessitating a comprehensive assessment before discharge.
*Laparotomy*
- **Laparotomy is a major open surgical procedure** reserved for cases with severe ischemia, perforation, or peritonitis, none of which are indicated by the patient's current status.
- The patient's stable vital signs and resolution of initial symptoms make this overly aggressive and unnecessary.
*Total parenteral nutrition*
- **Total parenteral nutrition (TPN) is used when the gastrointestinal tract cannot be used** for an extended period, such as in severe short bowel syndrome or prolonged postoperative ileus.
- The patient is currently on IV fluids and is NPO, but there's no indication of long-term inability to use his gut, and the nutritional support does not address the need for structural assessment of the colon.
Diverticular disease US Medical PG Question 9: A 43-year-old woman visits her primary care physician complaining of abdominal pain for the past 6 months. She reports that the pain is localized to her lower abdomen and often resolves with bowel movements. She states that some days she has diarrhea while other times she will go 4-5 days without having a bowel movement. She started a gluten-free diet in hopes that it would help her symptoms, but she has not noticed much improvement. She denies nausea, vomiting, hematochezia, or melena. Her medical history is significant for generalized anxiety disorder and hypothyroidism. Her father has a history of colon cancer. The patient takes citalopram and levothyroxine. Physical examination reveals mild abdominal tenderness with palpation of lower quadrant but no guarding or rebound. A guaiac test is negative. A complete blood count is pending. Which of the following is the next best step in management?
- A. Loperamide
- B. Thyroid ultrasound
- C. High fiber diet
- D. Anti-endomysial antibody titer
- E. Colonoscopy (Correct Answer)
Diverticular disease Explanation: ***Colonoscopy***
- Given her age (43 years), **family history of colon cancer** (father), and new-onset, fluctuating bowel habits with abdominal pain, a **colonoscopy** is indicated to rule out organic pathology.
- While her symptoms are suggestive of **irritable bowel syndrome (IBS)**, the **red flag symptom** of a family history of colon cancer necessitates further investigation beyond a clinical diagnosis of IBS.
*Loperamide*
- **Loperamide** is an antidiarrheal generally used for **symptomatic relief** in individuals with diarrhea-predominant IBS (IBS-D).
- Her symptoms fluctuate between diarrhea and constipation, and addressing the underlying cause or ruling out more serious conditions should precede symptomatic treatment.
*Thyroid ultrasound*
- She has a history of **hypothyroidism** and is on **levothyroxine**, but there is no indication of uncontrolled thyroid disease or a new thyroid issue.
- Her abdominal symptoms are unrelated to her thyroid condition, making a thyroid ultrasound an inappropriate next step.
*High fiber diet*
- A **high-fiber diet** can be beneficial for some forms of IBS, particularly **constipation-predominant IBS (IBS-C)**.
- However, it would not address the **red flag symptom** of family history of colon cancer and would not be the priority over ruling out malignancy.
*Anti-endomysial antibody titer*
- An **anti-endomysial antibody titer** is used to screen for **celiac disease**.
- While she tried a gluten-free diet, there are no other symptoms highly suggestive of celiac disease, and more importantly, this test would not address the **red flag concerns** for colorectal cancer.
Diverticular disease US Medical PG Question 10: A 65-year-old man presents to the emergency department with a fever and weakness. He states his symptoms started yesterday and have been gradually worsening. The patient has a past medical history of obesity, diabetes, alcohol abuse, as well as a 30 pack-year smoking history. He lives in a nursing home and has presented multiple times in the past for ulcers and delirium. His temperature is 103°F (39.4°C), blood pressure is 122/88 mmHg, pulse is 129/min, respirations are 24/min, and oxygen saturation is 99% on room air. Physical exam is notable for a murmur. The patient is started on vancomycin and piperacillin-tazobactam and is admitted to the medicine floor. During his hospital stay, blood cultures grow Streptococcus bovis and his antibiotics are appropriately altered. A transesophageal echocardiograph is within normal limits. The patient’s fever decreases and his symptoms improve. Which of the following is also necessary in this patient?
- A. Addiction medicine referral
- B. Colonoscopy (Correct Answer)
- C. Social work consult for elder abuse
- D. Repeat blood cultures for contamination concern
- E. Replace the patient’s central line and repeat echocardiography
Diverticular disease Explanation: ***Colonoscopy***
- The isolation of **_Streptococcus bovis_** (now often referred to as _Streptococcus gallolyticus_) from blood cultures is highly associated with **colorectal neoplasms** or other gastrointestinal pathologies.
- A comprehensive workup, including a **colonoscopy**, is crucial to identify the underlying source of bacteremia and screen for malignancy.
*Addiction medicine referral*
- While the patient has a history of **alcohol abuse**, there is no indication that his current presentation or the discovery of _Streptococcus bovis_ necessitates an immediate addiction medicine referral as the primary next step from an acute management perspective.
- Addiction management is an important long-term consideration but not the most pressing diagnostic need.
*Social work consult for elder abuse*
- The patient lives in a **nursing home** and has a history of delirium and frequent hospitalizations for ulcers, which can be concerning. However, there are no specific signs or symptoms presented in this vignette that directly suggest elder abuse as the reason for his current _S. bovis_ bacteremia, making it a less immediate priority compared to diagnosing the source of infection.
- While a general social work assessment might be beneficial for a vulnerable patient in a nursing home, it is not the most necessary intervention based on the microbiological finding.
*Repeat blood cultures for contamination concern*
- The question states that **_Streptococcus bovis_** blood cultures "grew" and antibiotics were "appropriately altered," suggesting a confirmed infection rather than contamination.
- Furthermore, _S. bovis_ is a known pathogen with specific associations and is not typically considered a common contaminant in the same vein as coagulase-negative staphylococci.
*Replace the patient’s central line and repeat echocardiography*
- The patient's **transesophageal echocardiogram (TEE) was normal**, ruling out endocarditis as the source of bacteremia in this case.
- There is no mention of a central line, and even if there were, the normal TEE and the specific pathogen (_S. bovis_) point towards a gastrointestinal source.
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