A four-week-old female is evaluated in the neonatal intensive care unit for feeding intolerance with gastric retention of formula. She was born at 25 weeks gestation to a 32-year-old gravida 1 due to preterm premature rupture of membranes at 24 weeks gestation. The patient’s birth weight was 750 g (1 lb 10 oz). She required resuscitation with mechanical ventilation at the time of delivery, but she was subsequently extubated to continuous positive airway pressure (CPAP) and then weaned to nasal cannula. The patient was initially receiving both parenteral nutrition and enteral feeds through a nasogastric tube, but she is now receiving only continuous nasogastric formula feeds. Her feeds are being advanced to a target weight gain of 20-30 g per day. Her current weight is 1,350 g (2 lb 16 oz). The patient’s temperature is 97.2°F (36.2°C), blood pressure is 72/54 mmHg, pulse is 138/min, respirations are 26/min, and SpO2 is 96% on 4L nasal cannula. On physical exam, the patient appears lethargic. Her abdomen is soft and markedly distended. Digital rectal exam reveals stool streaked with blood in the rectal vault. Which of the following abdominal radiographs would most likely be seen in this patient?
AAir in the biliary tree
BNormal bowel gas pattern
CDilated loops of bowel
DPneumoperitoneum
EPneumatosis intestinalis
A 47-year-old woman presents to the emergency department with abdominal pain. The patient states that she felt this pain come on during dinner last night. Since then, she has felt bloated, constipated, and has been vomiting. Her current medications include metformin, insulin, levothyroxine, and ibuprofen. Her temperature is 99.0°F (37.2°C), blood pressure is 139/79 mmHg, pulse is 95/min, respirations are 12/min, and oxygen saturation is 98% on room air. On physical exam, the patient appears uncomfortable. Abdominal exam is notable for hypoactive bowel sounds, abdominal distension, and diffuse tenderness in all four quadrants. Cardiac and pulmonary exams are within normal limits. Which of the following is the best next step in management?
AMetoclopramide
BNasogastric tube, NPO, and IV fluids
CStool guaiac
DEmergency surgery
EIV antibiotics and steroids
A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?
ADiagnostic peritoneal lavage
BEmergency laparotomy
CUpper gastrointestinal endoscopy
DClose observation
EDiagnostic laparoscopy
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