Question of the Week #482

A 63-year-old woman comes to the emergency department complaining of severe midabdominal pain. She reports that the pain has increased in intensity over the past few days. There has been no associated nausea or vomiting, no change in bowel habits, and no relief afforded by position changes. She is postmenopausal and does not take hormone replacement therapy. She has a 30-year history of hypertension, and has been noncompliant with her therapy of calcium channel blocker and thiazide diuretic. On examination her abdomen is obese but there is a suggestion of a nontender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following is the best next step in management?

A. Abdominal ultrasound
B. Abdominal CT scan without contrast
C. Abdominal CT scan with contrast
D. Angiography
E. Observation

Question of the Week # 463

463) A 48 year old woman presents to the emergency room with significant pain in the epi-gastrium and right upper quadrant. The pain has been persistent for the past 8 hours. She rates her pain at 8/10 in intensity. She reports some nausea but has not vomited. She has no jaundice. She denies any cough or burning urination or hematuria. On examination, she is obese, temperature is 99.9 F, blood pressure is at 120/80. She does not have any pallor or icterus. She lies still on the examination table since any movement aggravates her pain. She demands pain medication before you can examine her. An ultrasound of the abdomen is pending. What is the most appropriate next step?

A) Tell her that physical exam is done before analgesics since analgesia may obscure the diagnosis.
B) Give her morphine sulfate
C) Give her Meperidine
D) Obtain Urine drug screen
E) Tell her that you will not treat her pain without doing physical exam first

Question of the Week # 460

460)

A 65-year-old woman with a previous medical history of diabetes and rheumatoid arthritis underdoes an exploratory laparotomy for perforated sigmoid diverticulitis. Her postoperative stay is prolonged because of pneumonia, but is extubated on the fifth postoperative day and the next day discharged from the ICU to the floor. You are called by the nurse to check her wound as she noticed a new serous discharge. Her temperature is 37.0 C (98.6 F), pulse 100 beats/min, blood pressure 140/80 mm Hg, and blood glucose by finger stick 240 mg/dl. Abdomen is soft and non-tender. There is no induration, erythema, or crepitus of the wound. Copious amounts of serous brownish liquid are expressed from the wound on gentle pressure. Fluid is expressed spontaneously on coughing from both upper and lower parts of the wound. Which of the following is the most appropriate next step?
A. Start the patient on an insulin drip
B. Stop anticoagulation with subcutaneous heparin
C. Order dry dressings to be continued
D. Prescribe a 1-week course of antibiotics
E. Schedule the patient for wound exploration in the operating room

Question of the Week # 459

459) A 56-year-old man comes to the clinic complaining of postprandial nausea, occasional vomiting, and abdominal pain. Upon further questioning, he describes intermittent diarrhea and cramps, as well as diaphoresis, palpitations, and flushing. Three months ago he underwent resection of the distal stomach and proximal duodenum and gastrointestinal reconstruction due to complicated peptic ulcer disease. Prior to the operation, he had similar abdominal pain but it was usually relieved, not worsened with eating. Vital signs and physical examination are unremarkable. The most appropriate next step in the management of this patient is which of the following?
A. Begin a trial of somatostatin
B. Counsel the patient about his diet
C. Determine the patient’s gastrin level
D. Order a CT scan of the abdomen
E. Schedule a repeat endoscopy

Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration

Question of the Week # 432

432) A 62-year-old man presents with painless, progressive enlargement in the left side of his neck over the past 3 months. He denies any fever, night sweats or chills. He denies any pain, dysphagia, cough, hemoptysis, chestpain, shortness of breath, history of trauma or dental infection. His past medical history is significant for  100 pack-year history of smoking and daily alcohol abuse. On examination, he is afebrile. He has a large 5 cm , hard, non-tender and matted lymphadenopathy on the left lateral aspect of his neck . He has no other lymph node enlargement. No rash. Reminder of the exam including oral cavity examination is normal. There are no obvious tongue, pharyngeal or tonsillar lesions.  HIV and VDRL are negative. A CT scan of the chest, abdomen and pelvis does not reveal any lymphadenopathy or obvious mass lesions. Which of the following is the most appropriate next step in management?

A) Open biopsy of the neck mass

B) Pan-endoscopy

C)  Fine Needle Aspiration Cytology ( FNAC)

D) Test for HPV ( Human Papilloma Virus) and EBV ( Ebstein Barr Virus)

E) Prescribe antibiotic therapy and re-evaluate in 4 weeks

Question of the Week # 428

428) A 32-year-old male boxer presents to the emergency room after sustaining an injury during a local boxing match.  He was punched by the opponent over his right ear about six hours ago . He complains of pain and swelling over his right ear. He has no hearing deficit or tinnitus or headaches or blurred vision. He denies nausea or vomiting. Past medical history is unremarkable. On examination, his vitals are stable. His right ear is red, warm and swollen with a medium sized anterior auricular swelling which is tender to palpation. There is no facial swelling. If untreated, which of the following would be most likely course of this injury?

A) Spontaneous Resolution

B) Hearing Deficit

C) Permanent ear disfigurement

D) Otitis Externa

E) Mastoiditis

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