A 3-day-old newborn is brought to the physician because of abdominal distention, inconsolable crying, and 3 episodes of bilious vomiting since the previous evening. He was delivered at home at 40 weeks' gestation by a trained midwife. He has not passed meconium. Physical examination shows abdominal distention, a tight anal sphincter, and an explosive passage of air and feces on removal of the examining finger. Abnormal development of which of the following best explains this patient's condition?
Q2
A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had weight loss and a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable and thin man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 3,500/mm^3 with normal differential
Platelet count: 157,000/mm^3
Which of the following is the most appropriate next step in management?
Q3
A 70-year-old man with a history of chronic constipation presents to the emergency department with a two-day history of left lower quadrant abdominal pain. He is found to have a temperature of 100.8F, BP 140/90, HR 85, and RR 16. On physical examination, he is tender to light palpation in the left lower quadrant and exhibits voluntary guarding. Rectal examination reveals heme-positive stool. Laboratory values are unremarkable except for a WBC count of 12,500 with a left shift. Which of the following tests would be most useful in the diagnosis of this patient's disease?
Q4
A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
Q5
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?
Q6
A 67-year-old man presents to the emergency department with abdominal pain that started 1 hour ago. The patient has a past medical history of diabetes and hypertension as well as a 40 pack-year smoking history. His blood pressure is 107/58 mmHg, pulse is 130/min, respirations are 23/min, and oxygen saturation is 98% on room air. An abdominal ultrasound demonstrates focal dilation of the aorta with peri-aortic fluid. Which of the following is the best next step in management?
Q7
A 47-year-old woman is brought to the emergency department by her husband with the complaints of severe abdominal pain and discomfort. The pain began 2 days earlier, she describes it as radiating to her back and is associated with nausea. Her past medical history is significant for similar episodes of pain after fatty meals that resolved on its own. She drinks socially and has a 15 pack-year smoking history. Her pulse is 121/min, blood pressure is 121/71 mm Hg, and her temperature is 103.1°F (39.5°C). She has tenderness in the right upper quadrant and epigastrium with guarding and rebound tenderness. Bowel sounds are hypoactive. Part of a CBC is given below. What is the next best step in the management of this patient?
Hb%: 11 gm/dL
Total count (WBC): 13,400/mm3
Differential count:
Neutrophils: 80%
Lymphocytes: 15%
Monocytes: 5%
ESR: 45 mm/hr
C-reactive protein: 9.9 mg/dL (Normal < 3.0 mg/dL)
Q8
A 24-year-old woman recently noticed a mass in her left breast. The examination shows a 4-cm mass in the left upper quadrant. The mass is firm, mobile, and has well-defined margins. She complains of occasional tenderness. There is no lymphatic involvement. Mammography showed a dense lesion. What is the most likely cause?
Q9
A 24-year-old man presents to the emergency department after an altercation at a local bar. The patient was stabbed in the abdomen with a 6 inch kitchen knife in the epigastric region. His temperature is 97°F (36.1°C), blood pressure is 97/68 mmHg, pulse is 127/min, respirations are 19/min, and oxygen saturation is 99% on room air. Physical exam is notable for the knife in the patient’s abdomen in the location where he was initially stabbed. The patient is started on blood products and IV fluids. Which of the following is the best next step in management?
Q10
A 79-year-old man presents to the emergency department with abdominal pain. The patient describes the pain as severe, tearing, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking. He also has a previously diagnosed stable abdominal aortic aneurysm followed by ultrasound screening. On exam, the patient's temperature is 98°F (36.7°C), pulse is 113/min, blood pressure is 84/46 mmHg, respirations are 24/min, and oxygen saturation is 99% on room air. The patient is pale and diaphoretic, and becomes confused as you examine him. Which of the following is most appropriate in the evaluation and treatment of this patient?
Diverticulitis US Medical PG Practice Questions and MCQs
Question 1: A 3-day-old newborn is brought to the physician because of abdominal distention, inconsolable crying, and 3 episodes of bilious vomiting since the previous evening. He was delivered at home at 40 weeks' gestation by a trained midwife. He has not passed meconium. Physical examination shows abdominal distention, a tight anal sphincter, and an explosive passage of air and feces on removal of the examining finger. Abnormal development of which of the following best explains this patient's condition?
A. Submucosa and muscularis externa (Correct Answer)
B. Epithelium and submucosa
C. Muscularis mucosae and lamina propria
D. Muscularis mucosae and serosa
E. Epithelium and lamina propria
Explanation: ***Submucosa and muscularis externa***
- This patient's symptoms (abdominal distention, bilious vomiting, failure to pass meconium, tight anal sphincter with explosive stool passage) are classic for **Hirschsprung disease**.
- Hirschsprung disease is characterized by the absence of **ganglion cells** in the myenteric (Auerbach's) plexus (located between the inner circular and outer longitudinal layers of the muscularis externa) and the submucosal (Meissner's) plexus (located in the submucosa) of the distal colon.
*Epithelium and submucosa*
- The **epithelium** is involved in absorption and secretion, and its primary dysfunction would typically lead to diarrhea or malabsorption, not an obstructive picture like this.
- While the submucosa contains Meissner's plexus, the lack of ganglion cells in the muscularis externa's Auerbach's plexus is equally crucial to the pathophysiology of Hirschsprung disease.
*Muscularis mucosae and lamina propria*
- The **muscularis mucosae** is a thin layer that causes folding of the mucosa, while the **lamina propria** is connective tissue supporting the epithelium; neither is directly implicated in the primary pathology of Hirschsprung disease which involves neural crest cell migration.
- Absence of ganglion cells in these layers would not explain the severe motility disorder observed in Hirschsprung disease involving the entire bowel wall.
*Muscularis mucosae and serosa*
- The **serosa** is the outermost connective tissue layer and is not directly involved in the intrinsic innervation or motility problems seen in Hirschsprung disease.
- Dysfunction of the muscularis mucosae alone would not result in the functional obstruction due to absent peristalsis.
*Epithelium and lamina propria*
- The **epithelium** and **lamina propria** are primarily involved in the digestive and absorptive functions of the gut, and their abnormal development would not typically cause the characteristic features of Hirschsprung disease, which is a neurodevelopmental disorder of the gut.
- The core issue in Hirschsprung disease lies in the neural plexuses controlling motility, not the mucosal lining.
Question 2: A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had weight loss and a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable and thin man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 3,500/mm^3 with normal differential
Platelet count: 157,000/mm^3
Which of the following is the most appropriate next step in management?
A. Ceftriaxone and metronidazole
B. Ciprofloxacin and metronidazole
C. Colonoscopy
D. CT abdomen (Correct Answer)
E. MRI abdomen
Explanation: ***CT abdomen***
- A **CT scan of the abdomen and pelvis** is the most appropriate initial diagnostic step for acute left lower quadrant pain with fever, leukopenia, and a positive fecal occult blood test, as it can efficiently evaluate for **diverticulitis**, bowel perforation, or **colonic malignancy**.
- The patient's presentation with constitutional symptoms like **weight loss and decreased appetite** in an older male, along with signs of anemia and occult blood, raises concern for **colorectal cancer**, making imaging a critical next step to differentiate potential etiologies.
*Ceftriaxone and metronidazole*
- While this is a common antibiotic regimen for suspected **diverticulitis**, it should not be initiated without definitive imaging, especially given the patient's concerning systemic symptoms and signs of **anemia and occult bleeding**, which could indicate a more serious underlying condition.
- Empirical antibiotic therapy without a clear diagnosis could delay the identification of conditions like **colorectal cancer** or abscess, which require different management strategies.
*Ciprofloxacin and metronidazole*
- This is also a typical antibiotic combination for uncomplicated **diverticulitis**; however, giving antibiotics without confirmation of the diagnosis via imaging is inappropriate in this case due to the patient's **systemic symptoms** and signs of **GI bleeding**.
- Without imaging to rule out intestinal perforation or malignancy, starting antibiotics could mask symptoms or delay crucial diagnostic and therapeutic interventions.
*Colonoscopy*
- A **colonoscopy** is indicated to investigate the **positive fecal occult blood** and rule out colorectal malignancy, but it is generally *contraindicated* in the acute setting of suspected diverticulitis due to the risk of **perforation**.
- Imaging (like CT) should always precede colonoscopy when acute abdominal pain and inflammation are present to assess for safety and guide the timing of endoscopy.
*MRI abdomen*
- While **MRI provides excellent soft tissue delineation**, it is typically not the first-line imaging modality for acute abdominal pain presentations in the emergency department.
- **CT scans are faster, more readily available**, and provide comprehensive imaging of the bowel, mesentery, and surrounding structures, making them superior for initial evaluation of acute abdominal conditions like diverticulitis or perforation.
Question 3: A 70-year-old man with a history of chronic constipation presents to the emergency department with a two-day history of left lower quadrant abdominal pain. He is found to have a temperature of 100.8F, BP 140/90, HR 85, and RR 16. On physical examination, he is tender to light palpation in the left lower quadrant and exhibits voluntary guarding. Rectal examination reveals heme-positive stool. Laboratory values are unremarkable except for a WBC count of 12,500 with a left shift. Which of the following tests would be most useful in the diagnosis of this patient's disease?
A. Abdominal x-ray
B. Abdominal CT (Correct Answer)
C. Emergent colonoscopy
D. Left lower quadrant ultrasound
E. Lipase
Explanation: ***Abdominal CT***
- **CT scan** is the most accurate imaging modality for diagnosing **diverticulitis**, identifying bowel wall thickening, inflammation, and complications such as abscess formation.
- It effectively differentiates diverticulitis from other causes of **left lower quadrant pain** and can guide intervention if necessary.
*Abdominal x-ray*
- An **abdominal x-ray** is generally not useful for diagnosing **diverticulitis** as it provides limited soft tissue detail.
- It may identify free air in cases of perforation, but it is not sensitive or specific for diverticular inflammation.
*Emergent colonoscopy*
- **Colonoscopy** is generally contraindicated in acute **diverticulitis** due to the risk of **perforation** of the inflamed colon.
- It is typically performed after recovery from an acute episode (usually 4-6 weeks later) to rule out underlying malignancy or other inflammatory bowel conditions.
*Left lower quadrant ultrasound*
- While **ultrasound** can identify diverticulitis, its diagnostic accuracy is highly **operator-dependent** and can be limited by bowel gas.
- It is often less sensitive than CT, particularly for deeper structures or in obese patients, making **CT** the preferred initial imaging study.
*Lipase*
- **Lipase** is a marker for **pancreatitis** and is not relevant for the diagnosis of **diverticulitis**.
- The patient's symptoms are localized to the left lower quadrant and are not suggestive of pancreatic inflammation.
Question 4: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
A. "Does the diarrhea typically precede the constipation, or vice-versa?"
B. "Is the diarrhea foul-smelling?"
C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
D. "Are the symptoms worse in the morning or at night?"
E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Question 5: 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)
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.
Question 6: A 67-year-old man presents to the emergency department with abdominal pain that started 1 hour ago. The patient has a past medical history of diabetes and hypertension as well as a 40 pack-year smoking history. His blood pressure is 107/58 mmHg, pulse is 130/min, respirations are 23/min, and oxygen saturation is 98% on room air. An abdominal ultrasound demonstrates focal dilation of the aorta with peri-aortic fluid. Which of the following is the best next step in management?
A. Serial annual abdominal ultrasounds
B. Emergent surgical intervention (Correct Answer)
C. Administer labetalol
D. Counsel the patient in smoking cessation
E. Urgent surgery within the next day
Explanation: ***Emergent surgical intervention***
- The patient's presentation with acute **abdominal pain**, **hypotension**, and **tachycardia** combined with ultrasound findings of focal aortic dilation and peri-aortic fluid strongly suggests a **ruptured abdominal aortic aneurysm (AAA)**.
- A ruptured AAA is a life-threatening emergency requiring immediate surgical repair to prevent further hemorrhage and death.
*Serial annual abdominal ultrasounds*
- This approach is appropriate for asymptomatic patients with smaller, stable AAAs (typically <5.5 cm) to monitor for growth.
- In this case, the patient is symptomatic with signs of rupture, making surveillance an inappropriate and dangerous management strategy.
*Administer labetalol*
- Medications like labetalol are used to control blood pressure in conditions like aortic dissection or to slow the progression of AAAs, but they are contraindicated in hypotensive patients with a ruptured AAA.
- In this patient, labetalol would worsen the existing hypotension and could lead to cardiovascular collapse.
*Counsel the patient in smoking cessation*
- Smoking cessation is a crucial long-term intervention to reduce the risk of AAA expansion and rupture.
- While important, it does not address the immediate, life-threatening emergency of a ruptured AAA.
*Urgent surgery within the next day*
- Waiting until the next day for surgery in a patient with a suspected ruptured AAA is unacceptable.
- The patient's hemodynamic instability (hypotension, tachycardia) indicates active bleeding, and any delay significantly increases morbidity and mortality.
Question 7: A 47-year-old woman is brought to the emergency department by her husband with the complaints of severe abdominal pain and discomfort. The pain began 2 days earlier, she describes it as radiating to her back and is associated with nausea. Her past medical history is significant for similar episodes of pain after fatty meals that resolved on its own. She drinks socially and has a 15 pack-year smoking history. Her pulse is 121/min, blood pressure is 121/71 mm Hg, and her temperature is 103.1°F (39.5°C). She has tenderness in the right upper quadrant and epigastrium with guarding and rebound tenderness. Bowel sounds are hypoactive. Part of a CBC is given below. What is the next best step in the management of this patient?
Hb%: 11 gm/dL
Total count (WBC): 13,400/mm3
Differential count:
Neutrophils: 80%
Lymphocytes: 15%
Monocytes: 5%
ESR: 45 mm/hr
C-reactive protein: 9.9 mg/dL (Normal < 3.0 mg/dL)
A. Serum lipase levels
B. Ultrasound of the gallbladder (Correct Answer)
C. Erect abdominal X-ray
D. Upper GI endoscopy
E. Ultrasound of the appendix
Explanation: ***Ultrasound of the gallbladder***
- The patient presents with classic symptoms of **acute cholecystitis**, including severe right upper quadrant pain radiating to the back, fever, leukocytosis, and a history of similar pain after fatty meals.
- An ultrasound of the gallbladder is the **gold standard** for diagnosing cholecystitis, as it can visualize gallstones, gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy's sign.
*Serum lipase levels*
- While pancreatic involvement can occur, **serum lipase** is primarily used to diagnose **pancreatitis**, which typically presents with more severe epigastric pain and may or may not involve gallstones.
- The clinical picture here is more suggestive of cholecystitis, where gallbladder imaging is the priority.
*Erect abdominal X-ray*
- An **erect abdominal X-ray** is useful for detecting **free air under the diaphragm** in cases of bowel perforation or to assess for bowel obstruction.
- It is not the primary diagnostic tool for cholecystitis, as gallstones are often radiolucent and it does not provide detailed information about the gallbladder wall or surrounding structures.
*Upper GI endoscopy*
- **Upper GI endoscopy** is indicated for evaluating **esophageal, gastric, or duodenal pathologies**, such as ulcers, gastritis, or tumors.
- While peptic ulcer disease can cause epigastric pain, the patient's symptoms, especially the radiation to the back, fever, and history of pain after fatty meals, are more consistent with gallbladder disease, making endoscopy a less immediate diagnostic step.
*Ultrasound of the appendix*
- An **ultrasound of the appendix** is primarily used to diagnose **appendicitis**, which typically presents with periumbilical pain migrating to the right lower quadrant.
- The patient's pain is localized to the right upper quadrant and epigastrium, making appendicitis highly unlikely.
Question 8: A 24-year-old woman recently noticed a mass in her left breast. The examination shows a 4-cm mass in the left upper quadrant. The mass is firm, mobile, and has well-defined margins. She complains of occasional tenderness. There is no lymphatic involvement. Mammography showed a dense lesion. What is the most likely cause?
A. Phyllodes tumor
B. Invasive ductal carcinoma (IDC)
C. Inflammatory carcinoma
D. Ductal carcinoma in situ (DCIS)
E. Fibroadenoma (Correct Answer)
Explanation: ***Fibroadenoma***
- The patient's age (24 years old) and the description of the mass as **firm, mobile, with well-defined margins** are classic features of a fibroadenoma.
- Fibroadenomas are **benign stromal and epithelial tumors** of the breast, often presenting as non-tender or occasionally tender masses, especially common in younger women.
*Phyllodes tumor*
- While also a fibroepithelial tumor, phyllodes tumors tend to grow **rapidly** and can reach **larger sizes** (often >5 cm), with some having malignant potential.
- They are typically seen in **older women** (perimenopausal or postmenopausal) compared to the patient's age.
*Invasive ductal carcinoma (IDC)*
- IDC often presents as a **hard, irregular, fixed mass** with **poorly defined margins**, which is contrary to the description of a mobile, well-defined mass.
- Although it can occur at this age, it is less likely given the benign-appearing physical characteristics of the mass.
*Inflammatory carcinoma*
- This is an aggressive form of breast cancer characterized by **rapid onset of redness, warmth, swelling**, and a "peau d'orange" appearance due to lymphatic involvement, none of which are described.
- It does not typically present as a mobile, well-defined mass.
*Ductal carcinoma in situ (DCIS)*
- DCIS is a **non-invasive** carcinoma where atypical cells are confined to the breast ducts and usually presents as **microcalcifications on mammography**, often without a palpable mass.
- When it does present as a palpable mass, it is typically not mobile with well-defined margins.
Question 9: A 24-year-old man presents to the emergency department after an altercation at a local bar. The patient was stabbed in the abdomen with a 6 inch kitchen knife in the epigastric region. His temperature is 97°F (36.1°C), blood pressure is 97/68 mmHg, pulse is 127/min, respirations are 19/min, and oxygen saturation is 99% on room air. Physical exam is notable for the knife in the patient’s abdomen in the location where he was initially stabbed. The patient is started on blood products and IV fluids. Which of the following is the best next step in management?
A. Focused assessment with sonography in trauma (FAST) exam
B. CT scan of the abdomen
C. Diagnostic peritoneal lavage
D. Exploratory laparoscopy
E. Exploratory laparotomy (Correct Answer)
Explanation: ***Exploratory laparotomy***
- A patient presenting with a **penetrating abdominal injury** and signs of **hemodynamic instability** (BP 97/68 mmHg, pulse 127/min) requires immediate surgical intervention without further diagnostic studies.
- Since the knife is still in place, it is presumed to have caused a significant underlying visceral injury, and **exploratory laparotomy** is the definitive treatment to assess and repair internal damage.
*Focused assessment with sonography in trauma (FAST) exam*
- A FAST exam is useful for detecting **free fluid** in the abdomen in hemodynamically unstable patients with **blunt trauma**, but it is typically not sufficient for penetrating injuries.
- For a penetrating injury, even a negative FAST exam would not rule out significant organ damage that requires surgical exploration.
*CT scan of the abdomen*
- A CT scan can provide detailed imaging of abdominal organs and vessels but requires a **hemodynamically stable** patient, which this patient is not.
- Delaying definitive management by performing a CT scan in an unstable patient with a penetrating abdominal injury could worsen outcomes.
*Diagnostic peritoneal lavage*
- DPL is an invasive procedure that can detect the presence of **intra-abdominal bleeding** but has largely been replaced by FAST exams and CT scans for blunt trauma.
- In the setting of a clear penetrating injury with hemodynamic instability, DPL would delay definitive surgical management and is less specific than direct exploration.
*Exploratory laparoscopy*
- Laparoscopy can be used for **diagnostic** and **therapeutic** purposes in stable patients with penetrating abdominal trauma to assess the extent of injury.
- However, given the patient's **hemodynamic instability**, an open exploratory laparotomy provides faster access and control of potential major bleeding or organ damage.
Question 10: A 79-year-old man presents to the emergency department with abdominal pain. The patient describes the pain as severe, tearing, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking. He also has a previously diagnosed stable abdominal aortic aneurysm followed by ultrasound screening. On exam, the patient's temperature is 98°F (36.7°C), pulse is 113/min, blood pressure is 84/46 mmHg, respirations are 24/min, and oxygen saturation is 99% on room air. The patient is pale and diaphoretic, and becomes confused as you examine him. Which of the following is most appropriate in the evaluation and treatment of this patient?
A. Abdominal ultrasound
B. Abdominal CT with contrast
C. Surgery (Correct Answer)
D. Abdominal MRI
E. Abdominal CT without contrast
Explanation: ***Surgery***
- The patient presents with classic signs of a **ruptured abdominal aortic aneurysm (AAA)**, including sudden, severe, tearing abdominal pain radiating to the back, and signs of **hypovolemic shock** (hypotension, tachycardia, pallor, diaphoresis, confusion). Immediate surgical intervention is life-saving.
- Given the patient's **hemodynamic instability** and strong clinical suspicion for AAA rupture, delaying treatment for imaging studies is inappropriate and would significantly worsen the prognosis.
*Abdominal ultrasound*
- While ultrasound can detect an AAA, it is **less effective in identifying rupture**, especially retroperitoneal hemorrhage, and in hemodynamically unstable patients, the time spent on imaging is time lost for definitive treatment.
- The patient's critical condition warrants immediate intervention, and ultrasound would not provide enough detail or be fast enough to guide surgical planning in an emergency.
*Abdominal CT with contrast*
- CT angiography is the **gold standard for diagnosing AAA rupture** in stable patients, as it can visualize the aneurysm, rupture site, and extent of hemorrhage.
- However, for a **hemodynamically unstable patient** with a high clinical suspicion of rupture, taking the patient to CT risks further deterioration and delays life-saving surgery.
*Abdominal MRI*
- MRI is **contraindicated in unstable patients** due to the time required for imaging and the logistical challenges of monitoring critically ill patients in the MRI suite.
- It also provides no additional benefit over CT in an acute rupture setting and is generally not used for emergency AAA rupture diagnosis.
*Abdominal CT without contrast*
- A non-contrast CT might show the aneurysm and some signs of hemorrhage, but it would provide **less diagnostic information** regarding the rupture site and relationship to surrounding structures compared to a contrast-enhanced study.
- Like other imaging modalities, it still represents a **critical delay** for a patient in hypovolemic shock from a ruptured AAA, for whom immediate surgical intervention is paramount.
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