Day 18 Flashcards
Q1-Which of the following is most likely to benefit the patient?
A-Colonoscopy every 10 years after age 40
B-Colonoscopy every 10 years after age 50
C-Sigmoidoscopy every 3 to 5 years after 50
D-Barium enema after 50
E-Fecal occult blood testing
Ans: B. Colonoscopy is unquestionably the best of all the colon cancer screening methods. Sigmoidoscopy will miss the 40% of cancers occurring proximal to the sigmoid colon. Barium enema does not allow for biopsy or removal of polyps. Virtual colonoscopy misses cancers in polyps smaller than 0.5 cm. It is inferior to endoscopic colon cancer detection methods. Fecal occult blood testing will detect cancer. If positive, however, it must be followed by colonoscopy.
Q2- Which of the following is the strongest indication for meningococcal vaccination-who will benefit the most?
A-Asplenia
B-Military recruits
C-Residents of college dormitoriesd. Travelers to Mecca
D-11-year-old child
Ans: A. Asplenia represents a person at high risk for disseminated meningococcal infection. If he or she is exposed to the organism, an asplenic person has the highest risk of dissemination. The other choices represent increased exposure, but not an increased risk of immune compromise leading to dissemination.
Q3- An obese 59-year-old man presents to your office for preoperative evaluation after he decides to have an elective inguinal hernia repair. The patient’s past medical history is significant for hypertension, diabetes mellitus type 2 (DM2), and elevated cholesterol. Physical examination reveals a grade 3/6 systolic ejection murmur. How many risk factors does this patient have?
A-3
B-4
C-5
D-6
Ans: B. Diabetes is equivalent to having coronary artery disease. In addition, he is a man over the age of 45, is a known hypertensive, and has high cholesterol. Choices (C) through (F) are testing to see whether you can risk stratify a patient. The systolic ejection murmur is not considered a risk factor. This patient needs his blood pressure medications adjusted, daily finger sticks monitored, and insulin regimen adjusted. He would also need a stress test with ECG, and possibly an echo to assess his murmur.
Q4-A 45-year-old woman was texting while driving when she lost control of her car and ran into a tree. She is complaining of chest pain; physical examination reveals pallor, and cool extremities, a heart rate of 120 bpm, and JVD. Blood pressure is 80/40. Chest x-ray reveals 3 broken ribs over the left side of the chest.
Which of the following is the most likely type of shock?
A-Hypovolemic shock
B-Cardiogenic shock
C-Neurogenic shock
D-Septic shock
Ans: B. Cardiogenic shock is most likely secondary to pericardial tamponade. The patient’s car injury caused blood to collect in the pericardial sac, leading to right ventricular diastolic collapse and impaired filling. The broken ribs are the source of injury to the pericardium. Hypovolemic shock is unlikely, as the patient cannot lose that much volume into her pericardium. Neurogenic shock would have hyperreflexia and upgoing toes. Septic shock is unlikely as there is no fever and chills.
Q5- A 76-year-old woman is brought in for respiratory distress and altered mental status. Her medical history records right-sided hemiplegia from a stroke several years ago. She has blood pressure 86/52; heart rate 123 BPM, breathing rate 33 Br PM, temperature 102.3°F, and O2 sat 84%. Exam reveals rhonchi bilaterally with “E to Ah” changes and warm extremities with faint pulses. Chest x-ray shows bilateral infiltrates. What is the likely etiology of this patient’s hypotension?
A-Neurogenic shock B-Septic shock C-Hemorrhagic shock D-Hypovolemic shock E-Cardiogenic shock
Ans: B. This patient is presenting with 3 SIRS criteria: hypotension, altered mental status, and a source of infection (pneumonia). The physical exam is also consistent with septic shock: Massive vasodilation has yielded warm extremities and faint pulses. Both hypovolemic shock and cardiogenic shock would have pale and cool extremities. There is no mention of bleeding, ruling out hemorrhagic shock.
Q6- A 29-year-old man presents with severe abdominal pain that radiates to his back and began after his car was hit by another car. He says his abdomen hurts after colliding with the steering wheel. He is admitted, and after 2 days in the hospital a large ecchymosis is seen on the right flank. What is the most likely diagnosis?
A-Hemorrhagic pancreatitis
B-Pseudocyst
C-Renal trauma
D-Aortic dissection
Ans: A. The patient’s history of blunt abdominal trauma leads to the diagnosis of pancreatitis. The bruising and its flank location suggest a retroperitoneal hemorrhage. This is where blood collects in pancreatitis. Pseudocysts develop later, 6 to 8 weeks postpancreatitis. Renal trauma does not present with ecchymosis, and aortic dissection does not have bruising. Aortic dissection will present in a patient with extremely elevated BP and tearing midepigastric pain in the that radiates sharply into the back.
Q7- A 31-year-old woman presents to the ED with a sudden onset of left-sided chest pain and difficulty breathing. She states her only medication is birth control pills. She has smoked 1 pack of cigarettes per day for 10 years. She is tachypneic (24 BrPM) and her heart rate is 120 beats per minute. Physical examination reveals diminished breath sounds on the left and the trachea deviated to the right.
What is the most likely diagnosis?
A-Pericardial tamponade
B-Pulmonary embolus (PE)
C-Tension pneumothorax
D-Hemothorax
Ans: C. Tension pneumothorax presents with decreased breath sound on one side and tracheal deviation. PE does not give tracheal deviation, although it does have chest pain and tachycardia. Muffled heart sounds are seen typically in pericardial tamponade. This patient’s risk for pneumothorax is that she is a smoker. It is likely she has a pleural bleb that burst due to her smoking history.
Q8- A 20-year-old boy is hit by a car while riding his bicycle. He presents to the ED with severe groin pain after falling on the central bar of the bike. Physical examination reveals blood at the urethral meatus and a high-riding prostate.
What is the most appropriate next step in the management of this patient?
A-Place a Foley B-Get a retrograde urethrogram C-Empiric antibiotics D-CBC and electrolytes E-Discharge the patient with reassurance
Ans: B. The patient has a urethral disruption that needs to be evaluated. A kidney, ureters, and bladder (KUB) x-ray followed by a retrograde urethrogram must be conducted prior to any other tests. Placing a Foley catheter without such an imaging modality can lead to further urethral damage. The step after urethrogram is a Foley catheter placement to aid in urination. There is no role for antibiotics for trauma without evidence of infection.
Q9- A 73-year-old man with a history of atrial fibrillation, coronary artery disease (CAD), and dyslipidemia presents with severe abdominal pain that is worsened with eating. He states the pain is 10/10 but no peritoneal signs are present. Laboratory analysis shows a white count of 15 × 103/uL with increased neutrophils and decreased bicarbonate.
What is the most appropriate next step in management of this patient?
A-CT scan of the abdomen B-Angiography C-Liver function tests D-Colonoscopy E-Oral antibiotics
Ans: B. Angiography is the most appropriate next step in a patient suffering from acute mesenteric ischemia. The patient will present with complaints of abdominal pain that is severe and out of proportion to physical findings. This patient could also be a surgical candidate, but that was not an answer choice. Angiography is done prior to surgery as quickly as possible to avoid perforation; colonoscopy may lead to perforation.
Q10- A 67-year-old homeless woman presents to the ED with substernal chest pain that began shortly after vomiting. The patient has a history of alcoholism and has just finished a 3-day binge of vodka. Physical examination reveals a “snap, crackle, and pop” upon palpation around the clavicles. What is the most likely diagnosis?
A-Boerhaave syndrome B-Pancreatitis C-Biliary colic D-Volvulus E-Mycocardial infarction
Ans: A. Boerhaave syndrome is a full-thickness tear of the esophagus secondary to retching. The patient will have a history of severe incessant vomiting, often due to alcoholism. MI is unlikely in this patient given the subcutaneous emphysema. The other choices do not have substernal chest pain. Pancreatitis presents with abdominal pain that radiates to the back upon alcohol intake, not air in the subcutaneous space. Biliary colic has postprandial RUQ pain. Volvulus is malrotation of the colon.
Q11-A 55-year-old obese man presents with sudden onset of abdominal pain that radiates to his right shoulder. The patient also says he has vomited blood earlier in the day. The patient has a full bottle of esomeprazole in his pocket and says he uses those for his heartburn. Physical examination reveals rebound tenderness in the midepigastrum. Upright chest x-ray shows air under the diaphragm.
What is the most likely diagnosis?
A-Gastric perforation
B-Hemorrhagic ulcer
C-Cholecystitis
D-Ischemic colitis
Ans: A. This is gastric perforation in the setting of peptic ulcer disease. The patient’s bottle filled with PPIs is due to his history of ulcers. The fact that it is a full bottle implies the patient is noncompliant with his medication. Hemorrhagic ulcers will present with hematemesis, specifically coffee ground emesis. Cholecystitis would have right upper quadrant pain that is colicky in nature. Ischemic colitits would have an abdominal pain that is out of proportion to physical findings.
Q12-A11-year-old boy comes with decreased appetite and abdominal pain around his umbilicus. His parents think he doesn’t want to go to school, and while in math class he begins to have sharp pain in his right lower abdomen. He is rushed to the ED and laboratory analysis shows a WBC of 12,500. What is the most likely diagnosis?
A-Acute appendicitis
B-Acute diverticulitis
C-Cholecystitis
D-Acute pancreatitis
Ans: A. Acute appendicitis presents with pain that originates in the umbilical region and later begins to localize to the right lower quadrant. The patient will then develop signs of peritonitis. This patient is too young for diverticulitis. Diverticultitis also gives pain in the left lower quadrant. Cholecystitis would present with right upper quadrant pain. Pancreatitis would have midepigastric pain that radiates to the back with high amylase and lipase levels. The number one consideration is the location of the pain. It gives away 95% of the diagnosis.
Q13- A 74-year-old woman with no significant past medical history presents with severe left lower quadrant pain, fever, and anorexia of one day in duration. The patient’s daughter says her only medical history is that she is usually constipated and takes stool softeners every day to help her bowel movements. Physical exam shows guarding and rigidity.
What is the most likely diagnosis?
A-Acute appendicitis B-Acute diverticulitis C-Ectopic pregnancy D-Cholecystitis E-Acute pancreatitis
Ans: B. Acute diverticulitis has an acute onset of severe abdominal pain that is most likely located in the lower left quadrant. Patients with the first bout of diverticulitis are treated medically if there are no complications warranting surgery. However, recurrent diverticulitis will need resection of the affected loop of bowel. The most common complication after diverticulitis is abscess formation. Appendicitis gives pain in the right lower quadrant. Diverticulosis can occur anywhere in the colon, but in elderly patients, the sigmoid region is most involved, making it the most likely location for inflammation. Diverticulitis is highly associated with constipation. Pregnancy is implausible in this age group. Cholecystitis would have right upper quadrant pain. Pancreatitis would have pain that radiates to the back.
Q14- A 42-year-old obese woman with 5 children presents with a “gnawing” pain that recently has become severe. She notes the pain right after she finishes a meal and states that it radiates to her right shoulder. Physical exam reveals a cessation of inspiration upon palpation of the right upper quadrant and rebound tenderness. Laboratory analysis shows white cell count of 15,000 and a left shift.
What is the most likely diagnosis?
A-Acute appendicitis B-Acute diverticulitis C-Ectopic pregnancy D-Cholecystitis E-Acute pancreatitis
Ans: D. Acute cholecystitis is a common inflammatory condition that occurs often in obese women in their 40s. A gallstone occludes the lumen of the cystic duct. Patients have peritoneal signs and a positive Murphy sign. A sonographic Murphy sign is the ultrasound probe causing a cessation of breathing when it presses against the abdominal wall. On ultrasound, cholecystitis is characterized by pericholecystic fluid and a thickened gallbladder wall. Diverticulitis would be lower left or right quadrant pain in an elderly person with a history of constipation. Pancreatitis would have deep epigastric
Q15-A 65-year-old woman presents to the ED with nausea, vomiting, and severe abdominal pain that has gradually been increasing in intensity. She states that she has not had a bowel movement in 3 days and cannot remember the last time she passed gas. Her medical history is significant for an abdominal hysterectomy. Physical exam reveals a temperature of 101.5 and hyperactive bowel sounds, and the medical student thought he heard a tinkling sound. Laboratory results show a WBC count of 15,000.
What is the most likely diagnosis?
A-Acute appendicitis B-Acute diverticulitis C-Small bowel obstruction D-Cholecystitis E-Acute pancreatitis
Ans: C. Small bowel obstruction is characterized by failure to pass stool and flatus and a complete absence of bowel sounds. Nausea, vomiting, and abdominal pain with hyperactive bowel sounds are hallmarks. Past abdominal surgery is a very significant risk factor as adhesions can form from surgery. The other choices have abdominal pain localized to one quadrant, whereas with obstruction, diffuse unlocalized pain is seen.
