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?
Q72
A 54-year-old man with lymphoma presents to his oncologist with severe abdominal pain and flank pain. He says that the pain started 2 days ago and has gotten worse over time. He has also not been able to urinate over the same time period. On presentation, his temperature is 99°F (37.2°C), blood pressure is 110/72 mmHg, pulse is 105/min, and respirations are 12/min. Physical exam reveals bilateral flank tenderness. Labs results are shown below:
Blood urea nitrogen: 34 mg/dL
Creatinine: 3.7 mg/dl
Urine osmolality: 228 mOsm/kg
Renal ultrasonography shows dilation of the kidneys bilaterally with a normal-sized bladder. Which of the following would most likely be beneficial in treating this patient's condition?
Q73
A 19-year-old man comes to the emergency department because of abdominal pain, nausea, and vomiting for 4 hours. Initially, the pain was dull and located diffusely around his umbilicus, but it has now become sharper and moved towards his lower right side. He has no history of serious illness and takes no medications. His temperature is 38.2°C (100.7°F) and blood pressure is 123/80 mm Hg. Physical examination shows severe right lower quadrant tenderness without rebound or guarding; bowel sounds are decreased. His hemoglobin concentration is 14.2 g/dL, leukocyte count is 12,000/mm3, and platelet count is 280,000/mm3. Abdominal ultrasonography shows a dilated noncompressible appendix with distinct wall layers and echogenic periappendiceal fat. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
Q74
A 29-year-old woman, gravida 1, para 1, comes to the physician for the evaluation of a painful mass in her left breast for several days. She has no fevers or chills. She has not noticed any changes in the right breast. She has no history of serious illness. Her last menstrual period was 3 weeks ago. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 13/min, and blood pressure is 130/75 mm Hg. Examination shows a palpable, mobile, tender mass in the left upper quadrant of the breast. Ultrasound shows a 1.75-cm, well-circumscribed anechoic mass with posterior acoustic enhancement. The patient says that she is very concerned that she may have breast cancer and wishes further diagnostic testing. Which of the following is the most appropriate next step in the management of this patient?
Q75
A 61-year-old man comes to the physician because of a 2-month history of severe chest discomfort. The chest discomfort usually occurs after heavy meals or eating in the late evening and lasts several hours. He has nausea sometimes but no vomiting. He has also had an occasional nighttime cough during this period. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 41 years and drinks one beer daily. Current medications include metformin, naproxen, enalapril,and sitagliptin. He is 177 cm (5 ft 10 in) tall and weighs 135 kg (297 lb); BMI is 43 kg/m2. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Laboratory studies are within the reference ranges. An ECG shows no abnormalities. An upper endoscopy shows that the Z-line is located 4 cm above the diaphragmatic hiatus and reveals the presence of a 1.5-cm esophageal ulcer with an erythematous base and without bleeding. The physician recommends weight loss as well as smoking and alcohol cessation. Treatment with omeprazole is begun. One month later, his symptoms are unchanged. Which of the following is the most appropriate next step in management?
Q76
A 69-year-old male presents to the Emergency Department with bilious vomiting that started within the past 24 hours. His medical history is significant for hypertension, hyperlipidemia, and a myocardial infarction six months ago. His past surgical history is significant for a laparotomy 20 years ago for a perforated diverticulum. Most recently he had some dental work done and has been on narcotic pain medicine for the past week. He reports constipation and obstipation. He is afebrile with a blood pressure of 146/92 mm Hg and a heart rate of 116/min. His abdominal exam reveals multiple well-healed scars with distension but no tenderness. An abdominal/pelvic CT scan reveals dilated small bowel with a transition point to normal caliber bowel distally. When did the cause of his pathology commence?
Q77
A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?
Q78
A 62-year-old man presents to the office because of painless rectal bleeding for the past 3 months. He describes intermittent streaks of bright red blood on the toilet paper after wiping and blood on but not mixed within the stool. Occasionally, he has noted a small volume of blood within the toilet bowl, and he associates this with straining. For the past 2 weeks, he has noticed an 'uncomfortable lump' in his anus when defecating, which goes away by itself immediately afterwards. He says he has no abdominal pain, weight loss, or fevers. He is a well-appearing man that is slightly obese. Digital rectal examination shows bright red blood on the examination glove following the procedure. Anoscopy shows enlarged blood vessels above the pectinate line. Which of the following is the most likely cause?
Q79
A 26-year-old man presents to the emergency room with a complaint of lower abdominal pain that started about 5 hours ago. The pain was initially located around the umbilicus but later shifted to the right lower abdomen. It is a continuous dull, aching pain that does not radiate. He rates the severity of his pain as 7/10. He denies any previous history of similar symptoms. The vital signs include heart rate 100/min, respiratory rate 20/min, temperature 38.0°C (100.4°F), and blood pressure 114/77 mm Hg. On physical examination, there is severe right lower quadrant tenderness on palpation. Deep palpation of the left lower quadrant produces pain in the right lower quadrant. Rebound tenderness is present. The decision is made to place the patient on antibiotics and defer surgery. Two days later, his abdominal pain has worsened. Urgent computed tomography (CT) scan reveals new hepatic abscesses. The complete blood count result is given below:
Hemoglobin 16.2 mg/dL
Hematocrit 48%
Leukocyte count 15,000/mm³
Neutrophils 69%
Bands 3%
Eosinophils 1%
Basophils 0%
Lymphocytes 24%
Monocytes 3%
Platelet count 380,000/mm³
Which of the following complications has this patient most likely experienced?
Q80
A 68-year-old man presents with a 3-month history of difficulty starting urination, weak stream, and terminal dribbling. The patient has no history of serious illnesses and is not under any medications currently. The patient’s father had prostate cancer at the age of 58 years. Vital signs are within normal range. Upon examination, the urinary bladder is not palpable. Further examination reveals normal anal sphincter tone and a bulbocavernosus muscle reflex. Digital rectal exam (DRE) shows a prostate size equivalent to 2 finger pads with a hard nodule and without fluctuance or tenderness. The prostate-specific antigen (PSA) level is 5 ng/mL. Image-guided biopsy indicates prostate cancer. MRI shows tumor confined within the prostate. Radionuclide bone scan reveals no abnormalities. Which of the following interventions is the most appropriate next step in the management of this patient?
Abdominal emergencies US Medical PG Practice Questions and MCQs
Question 71: 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 72: A 54-year-old man with lymphoma presents to his oncologist with severe abdominal pain and flank pain. He says that the pain started 2 days ago and has gotten worse over time. He has also not been able to urinate over the same time period. On presentation, his temperature is 99°F (37.2°C), blood pressure is 110/72 mmHg, pulse is 105/min, and respirations are 12/min. Physical exam reveals bilateral flank tenderness. Labs results are shown below:
Blood urea nitrogen: 34 mg/dL
Creatinine: 3.7 mg/dl
Urine osmolality: 228 mOsm/kg
Renal ultrasonography shows dilation of the kidneys bilaterally with a normal-sized bladder. Which of the following would most likely be beneficial in treating this patient's condition?
A. Catheterization of the bladder
B. Bilateral stenting of the renal arteries
C. Administration of a loop diuretic
D. Volume repletion with saline
E. Bilateral stenting of the ureters (Correct Answer)
Explanation: ***Bilateral stenting of the ureters***
- The patient presents with **acute kidney injury (AKI)**, bilateral flank pain, and anuria, along with **bilateral hydronephrosis** and a normal bladder on ultrasound. This clinical picture is highly suggestive of **bilateral ureteral obstruction**.
- **Ureteral stenting** would relieve the obstruction, allowing urine flow and improving kidney function. Lymphoma can cause external compression of the ureters, leading to post-renal AKI.
*Catheterization of the bladder*
- The ultrasound shows a **normal-sized bladder**, indicating that there is no obstruction at or below the bladder outlet.
- Therefore, bladder catheterization would not relieve the obstruction causing hydronephrosis and would not improve the patient's anuria.
*Bilateral stenting of the renal arteries*
- This intervention is used for **renal artery stenosis**, which typically presents with hypertension, flash pulmonary edema, or progressive renal insufficiency, but not with bilateral hydronephrosis or acute anuria in this setting.
- The patient's presentation points to a **post-renal cause** of AKI, not a pre-renal (vascular) cause.
*Administration of a loop diuretic*
- Loop diuretics increase urine output by acting on the **loop of Henle**, but they are ineffective and potentially harmful in the setting of a complete urinary tract obstruction.
- Administering diuretics without relieving the obstruction would not only fail to resolve the anuria but could also worsen the patient's fluid and electrolyte balance.
*Volume repletion with saline*
- While patients with AKI can sometimes benefit from repletion, the primary issue here is **obstruction**, not intravascular volume depletion leading to pre-renal AKI.
- The patient's blood pressure is stable, and there are no signs pointing specifically to hypovolemia as the cause of his AKI. Correcting the obstruction is the priority.
Question 73: A 19-year-old man comes to the emergency department because of abdominal pain, nausea, and vomiting for 4 hours. Initially, the pain was dull and located diffusely around his umbilicus, but it has now become sharper and moved towards his lower right side. He has no history of serious illness and takes no medications. His temperature is 38.2°C (100.7°F) and blood pressure is 123/80 mm Hg. Physical examination shows severe right lower quadrant tenderness without rebound or guarding; bowel sounds are decreased. His hemoglobin concentration is 14.2 g/dL, leukocyte count is 12,000/mm3, and platelet count is 280,000/mm3. Abdominal ultrasonography shows a dilated noncompressible appendix with distinct wall layers and echogenic periappendiceal fat. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
A. Prescribe oral amoxicillin and clavulanic acid
B. Perform laparoscopic appendectomy (Correct Answer)
C. Perform percutaneous drainage
D. Perform interval appendectomy
E. Begin bowel rest and nasogastric aspiration
Explanation: ***Perform laparoscopic appendectomy***
- The patient presents with classic symptoms of **acute appendicitis**, including periumbilical pain migrating to the right lower quadrant, localized tenderness, fever, and leukocytosis.
- Abdominal ultrasonography showing a **dilated noncompressible appendix** with echogenic periappendiceal fat further confirms the diagnosis, making surgical removal the most appropriate and definitive treatment.
*Prescribe oral amoxicillin and clavulanic acid*
- While antibiotics are often given pre-operatively, they are not the definitive treatment for **acute appendicitis**, especially with clear imaging findings.
- Relying solely on antibiotics in this scenario would risk **perforation** and increased morbidity.
*Perform percutaneous drainage*
- Percutaneous drainage is typically reserved for **appendiceal abscesses** or phlegmons, especially if the patient is unstable or the inflammation is walled off.
- There is no mention of an abscess in this patient's presentation or imaging, making surgical removal of the inflamed appendix the primary treatment.
*Perform interval appendectomy*
- **Interval appendectomy** is considered for patients who initially respond to conservative antibiotic management for an appendiceal mass or phlegmon.
- Since this patient has acute symptoms with clear ultrasound findings of appendicitis without mention of an abscess that would necessitate conservative management, immediate surgical intervention is indicated.
*Begin bowel rest and nasogastric aspiration*
- Bowel rest and nasogastric aspiration are indicated for conditions like **bowel obstruction** or severe **pancreatitis** to decompress the gastrointestinal tract.
- These measures do not address the underlying inflammation and obstruction of acute appendicitis and would delay definitive treatment, increasing the risk of complications.
Question 74: A 29-year-old woman, gravida 1, para 1, comes to the physician for the evaluation of a painful mass in her left breast for several days. She has no fevers or chills. She has not noticed any changes in the right breast. She has no history of serious illness. Her last menstrual period was 3 weeks ago. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 13/min, and blood pressure is 130/75 mm Hg. Examination shows a palpable, mobile, tender mass in the left upper quadrant of the breast. Ultrasound shows a 1.75-cm, well-circumscribed anechoic mass with posterior acoustic enhancement. The patient says that she is very concerned that she may have breast cancer and wishes further diagnostic testing. Which of the following is the most appropriate next step in the management of this patient?
A. Core needle biopsy
B. MRI scan of the left breast
C. Reassurance and clinical follow-up
D. Fine needle aspiration (Correct Answer)
E. Mammogram
Explanation: ***Fine needle aspiration***
- This patient presents with a **palpable, mobile, tender mass** in the breast, and ultrasound reveals a **well-circumscribed anechoic mass with posterior acoustic enhancement**, which is highly suggestive of a **simple cyst**.
- **Fine needle aspiration** is the most appropriate next step for a symptomatic simple cyst; it can be both diagnostic and therapeutic, relieving patient anxiety and pain.
*Core needle biopsy*
- **Core needle biopsy** is typically reserved for lesions that are suspicious for malignancy, such as solid masses with **irregular margins** or **architectural distortion**, which are not present in this case.
- Performing a core needle biopsy on a likely simple cyst is excessively invasive and carries risks like bleeding and infection without clear indication.
*MRI scan of the left breast*
- An **MRI scan** is generally used for screening high-risk patients, evaluating the extent of known cancer, or further characterizing complex lesions not clearly defined by mammography and ultrasound.
- It is not indicated for a lesion that is highly characteristic of a **simple cyst** on ultrasound, as it would be an unnecessary and costly procedure.
*Reassurance and clinical follow-up*
- While the ultrasound findings are reassuring, her symptoms (painful mass) and anxiety warrant intervention. **Reassurance alone** is insufficient, as aspiration would confirm the diagnosis and relieve symptoms.
- Dismissing the patient's concerns without further action, especially with a symptomatic mass, is not the best practice and may cause undue stress.
*Mammogram*
- A **mammogram** would be less helpful in this young woman with dense breast tissue, and ultrasound has already characterized the lesion as a cyst.
- Furthermore, for a clearly cystic lesion, mammography provides little additional diagnostic information and exposes the patient to unnecessary radiation.
Question 75: A 61-year-old man comes to the physician because of a 2-month history of severe chest discomfort. The chest discomfort usually occurs after heavy meals or eating in the late evening and lasts several hours. He has nausea sometimes but no vomiting. He has also had an occasional nighttime cough during this period. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 41 years and drinks one beer daily. Current medications include metformin, naproxen, enalapril,and sitagliptin. He is 177 cm (5 ft 10 in) tall and weighs 135 kg (297 lb); BMI is 43 kg/m2. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Laboratory studies are within the reference ranges. An ECG shows no abnormalities. An upper endoscopy shows that the Z-line is located 4 cm above the diaphragmatic hiatus and reveals the presence of a 1.5-cm esophageal ulcer with an erythematous base and without bleeding. The physician recommends weight loss as well as smoking and alcohol cessation. Treatment with omeprazole is begun. One month later, his symptoms are unchanged. Which of the following is the most appropriate next step in management?
A. Laparoscopic Nissen fundoplication with hiatoplasty (Correct Answer)
B. Clarithromycin, amoxicillin, and omeprazole therapy for 2 weeks
C. Calcium carbonate therapy for 2 months
D. Bariatric surgery
E. Laparoscopic herniotomy
Explanation: ***Laparoscopic Nissen fundoplication with hiatoplasty***
- The patient has severe gastroesophageal reflux disease (GERD) symptoms unresponsive to **proton pump inhibitor (PPI)** therapy, significant esophageal ulceration, and a large **hiatal hernia** (Z-line 4 cm above diaphragmatic hiatus), making surgical intervention appropriate.
- **Nissen fundoplication** reconstructs the lower esophageal sphincter, and **hiatoplasty** repairs the hiatal hernia, directly addressing the anatomical and physiological causes of his persistent reflux and severe symptoms.
*Clarithromycin, amoxicillin, and omeprazole therapy for 2 weeks*
- This **triple therapy** regimen is indicated for **Helicobacter pylori** eradication in patients with peptic ulcer disease.
- While the patient has an esophageal ulcer, there is no mention of *H. pylori* infection, and his symptoms are more consistent with GERD and a hiatal hernia.
*Calcium carbonate therapy for 2 months*
- **Calcium carbonate** is an **antacid** that provides temporary symptomatic relief by neutralizing stomach acid.
- It is insufficient for severe GERD with esophageal ulceration and a hiatal hernia, especially when PPI therapy has failed.
*Bariatric surgery*
- While the patient has a high BMI (43 kg/m2) and obesity can exacerbate GERD, bariatric surgery is primarily indicated for weight loss and its related comorbidities.
- It does not directly address the anatomical defect of the **hiatal hernia** or severe reflux symptoms refractory to medical management in the same specific way as anti-reflux surgery.
*Laparoscopic herniotomy*
- A **herniotomy** involves excising the peritoneal sac of a hernia, commonly used for inguinal or umbilical hernias.
- While the patient has a hiatal hernia, the procedure required is specifically a **hiatoplasty** to repair the diaphragmatic defect, often combined with a fundoplication for GERD.
Question 76: A 69-year-old male presents to the Emergency Department with bilious vomiting that started within the past 24 hours. His medical history is significant for hypertension, hyperlipidemia, and a myocardial infarction six months ago. His past surgical history is significant for a laparotomy 20 years ago for a perforated diverticulum. Most recently he had some dental work done and has been on narcotic pain medicine for the past week. He reports constipation and obstipation. He is afebrile with a blood pressure of 146/92 mm Hg and a heart rate of 116/min. His abdominal exam reveals multiple well-healed scars with distension but no tenderness. An abdominal/pelvic CT scan reveals dilated small bowel with a transition point to normal caliber bowel distally. When did the cause of his pathology commence?
A. One week ago
B. Six months ago
C. 20 years ago (Correct Answer)
D. At birth
E. 24 hours ago
Explanation: ***20 years ago***
- The patient's history of a **laparotomy 20 years ago** for a perforated diverticulum is the most likely cause of his current small bowel obstruction. **Adhesions** from prior abdominal surgery are the leading cause of small bowel obstruction.
- The CT scan finding of **dilated small bowel** with a **transition point** confirms a mechanical obstruction, and the operative scarring supports adhesions as the etiology.
*One week ago*
- While **narcotic pain medicine** can cause constipation and ileus, it typically leads to a more diffuse distention without a clear transition point characteristic of a mechanical obstruction.
- The development of a clear transition point on CT after only one week of narcotic use makes a mechanical obstruction from adhesions more likely than a pure narcotic-induced ileus.
*Six months ago*
- A **myocardial infarction** six months ago is not directly related to the development of a small bowel obstruction.
- While cardiac events can sometimes lead to mesenteric ischemia, the CT findings of a transition point are more indicative of a mechanical obstruction rather than ischemia.
*At birth*
- Congenital conditions causing small bowel obstruction, such as **atresia** or **malrotation**, typically present in infancy or early childhood.
- Given the patient's age and history of prior abdominal surgery, a congenital cause is highly unlikely.
*24 hours ago*
- The onset of symptoms within the past 24 hours describes the **acute presentation** of the obstruction, not its underlying cause.
- The obstruction itself developed over time due to a predisposing factor from his past medical history.
Question 77: A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?
A. Small bowel resection with ileostomy
B. Abdominal closure and start palliative care
C. Small bowel resection and primary anastomosis
D. Strictureplasty of individual strictures (Correct Answer)
E. Ileocolectomy
Explanation: ***Strictureplasty of individual strictures***
- This patient presents with **multiple strictures** in the mid-ileum causing a small bowel obstruction in the setting of **Crohn's disease**. Strictureplasty is the preferred surgical approach for *short, multiple (up to four), or recurrent Crohn's disease strictures* as it preserves bowel length.
- While small bowel resection is an option, **strictureplasty** is favored in Crohn's disease to *avoid short bowel syndrome*, especially if multiple strictures are present, as seen here.
*Small bowel resection with ileostomy*
- An ileostomy is typically created when a primary anastomosis is not safe due to high risk of leak (e.g., severe inflammation, peritonitis, patient instability) or when there is extensive disease not amenable to strictureplasty with primary anastomosis.
- Performing an ileostomy when primary anastomosis is possible unnecessarily creates a stoma, which can lead to complications and impact quality of life.
*Abdominal closure and start palliative care*
- This patient, while acutely unwell, has a surgically correctable cause for his obstruction and is not described as having an incurable or end-stage condition necessitating only palliative care.
- Palliative care would be considered for patients with widespread untreatable disease or severe comorbidities, which is not indicated here given the localized, treatable strictures.
*Small bowel resection and primary anastomosis*
- While small bowel resection is a valid treatment for isolated, non-recurrent strictures, strictureplasty is generally preferred in Crohn's disease when multiple strictures are present.
- **Resection of multiple segments** can lead to significant **short bowel syndrome**, especially in a patient with a history of prior small bowel resection, making strictureplasty a more bowel-sparing and appropriate choice.
*Ileocolectomy*
- **Ileocolectomy** involves resection of the terminal ileum and a portion of the colon. This would be indicated if the disease involves the *ileocecal valve region* or the *colon*, which is not the case in this patient, whose strictures are in the mid-ileum.
- This procedure is excessive for mid-ileal strictures and would result in unnecessary removal of healthy bowel given the location of the strictures.
Question 78: A 62-year-old man presents to the office because of painless rectal bleeding for the past 3 months. He describes intermittent streaks of bright red blood on the toilet paper after wiping and blood on but not mixed within the stool. Occasionally, he has noted a small volume of blood within the toilet bowl, and he associates this with straining. For the past 2 weeks, he has noticed an 'uncomfortable lump' in his anus when defecating, which goes away by itself immediately afterwards. He says he has no abdominal pain, weight loss, or fevers. He is a well-appearing man that is slightly obese. Digital rectal examination shows bright red blood on the examination glove following the procedure. Anoscopy shows enlarged blood vessels above the pectinate line. Which of the following is the most likely cause?
A. Grade 2 internal hemorrhoids (Correct Answer)
B. Grade 3 internal hemorrhoids
C. Thrombosed external hemorrhoids
D. Grade 1 internal hemorrhoids
E. Grade 4 internal hemorrhoids
Explanation: ***Grade 2 internal hemorrhoids***
- The patient's symptoms of **painless bleeding**, a **lump during defecation** that **reduces spontaneously**, and **enlarged vessels above the pectinate line** on anoscopy are classic for grade 2 internal hemorrhoids.
- **Internal hemorrhoids** originate above the pectinate line, are typically painless due to visceral innervation, and **grade 2** specifically refers to prolapse during defecation with spontaneous reduction.
*Grade 3 internal hemorrhoids*
- **Grade 3** internal hemorrhoids also prolapse during defecation but require **manual reduction**.
- The patient's description of the lump "going away by itself immediately afterwards" indicates **spontaneous reduction**, not manual reduction, making this grade 2 rather than grade 3.
*Thrombosed external hemorrhoids*
- **External hemorrhoids** occur **below the pectinate line** and are typically **painful**, especially when thrombosed, due to somatic innervation.
- The anoscopy finding of enlarged vessels **above the pectinate line** and the **painless** nature of bleeding definitively rule out external hemorrhoids.
*Grade 1 internal hemorrhoids*
- These are **enlarged vessels above the pectinate line** but **do not prolapse** during defecation.
- The patient describes an "uncomfortable lump" that appears with defecation, indicating **prolapse**, which is inconsistent with grade 1 (bleeding only, no prolapse).
*Grade 4 internal hemorrhoids*
- **Grade 4** internal hemorrhoids are **permanently prolapsed** and **cannot be reduced**, even manually.
- The patient's symptoms of a lump that "goes away by itself immediately afterwards" indicate spontaneous reduction, ruling out grade 4.
Question 79: A 26-year-old man presents to the emergency room with a complaint of lower abdominal pain that started about 5 hours ago. The pain was initially located around the umbilicus but later shifted to the right lower abdomen. It is a continuous dull, aching pain that does not radiate. He rates the severity of his pain as 7/10. He denies any previous history of similar symptoms. The vital signs include heart rate 100/min, respiratory rate 20/min, temperature 38.0°C (100.4°F), and blood pressure 114/77 mm Hg. On physical examination, there is severe right lower quadrant tenderness on palpation. Deep palpation of the left lower quadrant produces pain in the right lower quadrant. Rebound tenderness is present. The decision is made to place the patient on antibiotics and defer surgery. Two days later, his abdominal pain has worsened. Urgent computed tomography (CT) scan reveals new hepatic abscesses. The complete blood count result is given below:
Hemoglobin 16.2 mg/dL
Hematocrit 48%
Leukocyte count 15,000/mm³
Neutrophils 69%
Bands 3%
Eosinophils 1%
Basophils 0%
Lymphocytes 24%
Monocytes 3%
Platelet count 380,000/mm³
Which of the following complications has this patient most likely experienced?
A. Perforation
B. Appendiceal abscess
C. Pylephlebitis (Correct Answer)
D. Intestinal obstruction
E. Peritonitis
Explanation: ***Pylephlebitis***
- The development of **hepatic abscesses** following acute appendicitis, especially after a delay in surgical intervention, is strongly indicative of **pylephlebitis**. This condition involves septic thrombophlebitis of the **portal venous system**, allowing bacteria from the infected appendix to seed the liver.
- The initial signs of appendicitis, such as **periumbilical pain migrating to the right lower quadrant**, fever, leukocytosis, and right lower quadrant tenderness (including positive Rovsing's sign and rebound tenderness), suggest an acute appendicular inflammation that likely progressed and led to this serious complication.
*Perforation*
- While appendiceal perforation is a common complication of acute appendicitis, it typically leads to **generalized peritonitis** or a **localized abscess** around the appendix, not the development of new hepatic abscesses days later without direct evidence of free perforation.
- The worsening pain and new hepatic abscesses suggest a more systemic spread of infection via the venous system rather than a direct localized spill from a perforation.
*Appendiceal abscess*
- An appendiceal abscess is a localized collection of pus around the appendix, which can occur if the inflamed appendix perforates and is walled off by contiguous structures. While this is a common complication, it would typically appear as a collection near the appendix on imaging, not as **new hepatic abscesses** days later.
- Although it indicates a more severe, possibly perforated, appendix, it doesn't directly explain the **liver involvement** seen in this patient's CT scan.
*Intestinal obstruction*
- Intestinal obstruction can occur due to severe appendicitis causing adhesion formation or local inflammation, but it would present with symptoms like **nausea, vomiting, abdominal distension, and altered bowel habits**, which are not detailed here.
- **Hepatic abscesses** are not a direct or typical consequence of intestinal obstruction caused by appendicitis.
*Peritonitis*
- Peritonitis results from inflammation of the peritoneum, often due to a perforated appendix. It typically presents with **severe, diffuse abdominal pain, guarding, and rigidity**. While the patient has rebound tenderness, which suggests peritoneal irritation, the development of new hepatic abscesses as the primary worsening sign points to a **specific vascular spread** rather than generalized peritonitis.
- The delay in surgical intervention likely allowed the infection to spread via the **portal venous system**, leading to the liver abscesses, which is a more specific diagnosis than just peritonitis.
Question 80: A 68-year-old man presents with a 3-month history of difficulty starting urination, weak stream, and terminal dribbling. The patient has no history of serious illnesses and is not under any medications currently. The patient’s father had prostate cancer at the age of 58 years. Vital signs are within normal range. Upon examination, the urinary bladder is not palpable. Further examination reveals normal anal sphincter tone and a bulbocavernosus muscle reflex. Digital rectal exam (DRE) shows a prostate size equivalent to 2 finger pads with a hard nodule and without fluctuance or tenderness. The prostate-specific antigen (PSA) level is 5 ng/mL. Image-guided biopsy indicates prostate cancer. MRI shows tumor confined within the prostate. Radionuclide bone scan reveals no abnormalities. Which of the following interventions is the most appropriate next step in the management of this patient?
A. Radiation therapy + androgen deprivation therapy (Correct Answer)
B. Finasteride + tamsulosin
C. Chemotherapy + androgen deprivation therapy
D. Radical prostatectomy + chemotherapy
E. Radical prostatectomy + radiation therapy
Explanation: ***Radiation therapy + androgen deprivation therapy***
- This patient presents with **localized prostate cancer** (tumor confined to the prostate with no evidence of metastasis) that requires definitive treatment.
- The presence of a **hard nodule on DRE** with a **family history of early-onset prostate cancer** (father diagnosed at age 58) suggests potentially **intermediate-risk disease** that may warrant combination therapy.
- **Radiation therapy with androgen deprivation therapy (ADT)** is an evidence-based, guideline-recommended treatment for localized prostate cancer, particularly for intermediate to high-risk cases, and has been shown to improve overall survival and disease-free survival compared to radiation alone.
- This approach is appropriate for a 68-year-old patient and avoids surgical morbidity while providing excellent oncological outcomes.
*Radical prostatectomy + radiation therapy*
- While **radical prostatectomy** is a valid primary treatment for localized prostate cancer, combining it upfront with radiation therapy is **not standard practice**.
- **Adjuvant radiation** is only considered **after surgery** if pathology reveals adverse features such as positive surgical margins, extracapsular extension, or seminal vesicle invasion—findings that cannot be determined preoperatively.
- For localized disease, treatment is either surgery **or** radiation, not both simultaneously.
*Finasteride + tamsulosin*
- **Finasteride** (a 5-alpha-reductase inhibitor) and **tamsulosin** (an alpha-blocker) are used to manage **benign prostatic hyperplasia (BPH)** symptoms.
- These medications do not treat prostate cancer and are inappropriate once malignancy is confirmed by biopsy.
*Chemotherapy + androgen deprivation therapy*
- **Chemotherapy** (e.g., docetaxel) is reserved for **metastatic castration-resistant prostate cancer** or metastatic hormone-sensitive disease.
- This patient has **localized disease** with negative bone scan and MRI showing tumor confined to the prostate, making chemotherapy inappropriate.
*Radical prostatectomy + chemotherapy*
- While **radical prostatectomy** can be appropriate for localized prostate cancer, **chemotherapy** is not used adjuvantly for localized disease without metastasis.
- Chemotherapy is reserved for advanced, metastatic, or castration-resistant disease.
