GI Year 2 (Not from USUHS, but recommended to us)

Question 1

A 72-year-old woman presents with a 4-day history of abdominal distention, pain, and constipation. She reports that it has been about one week since her last bowel movement. Over the past 24 hours, she has become nauseated and vomited twice. She denies fever. Review of symptoms reveals a 15-pound weight loss over the past 2 months.

Physical Exam findings:

T 98.8 degrees F oral, Pulse: 92 beats/min, Resp rate: 16 breaths/min, BP 138/32 mm Hg

GEN: Mild pallor. Appears moderatetly ill.

HEENT: dry oral mucosa

Lungs: clear to auscultation with normal movements

HEART: RRR w/o M/G/R

ABD: protuberant, generalized tympany to percussion, mild generalized tenderness w/o rebound or guarding.

Rectal: No masses. Heme positive stool

An upright abdominal Xray is attached.

Which of the following is the most likely diagnosis?

Choices:

Large Bowel Obstruction

Small Bowel Obstruction

Diverticulitis

Appendicitis

Gastroenteritis

Answer 1

Large Bowel Obstruction

Explanation:

The correct answer is large bowel obstruction. The history of abdominal distention, constipation, pain, and vomiting should make you consider a bowel obstruction. Although most bowel obstructions are in the small bowel, findings on the upright abdominal xray of dilation of the large bowel with air fluid levels and haustra (the transverse lines that differentiate large from small bowel, confirm the diagnosis.

A: Haustra

b. Air fluid levels

Question 2

Which of the areas marked in the picture corresponds to McBurney’s point?

Answer 2

A.

Explanation:

McBurney’s point is also described as one third the distance from the iliac spine to the umbilicus. It is the surface anatomy point underwhich you are most likely to find the appendix.

Question 3

A 23-year-old woman presents because of right-sided abdominal pain worsening over the past 3 days. The pain began initially in the area of the umbilicus, and centers now in the right lower quadrant, radiating to the back. She has had some nausea and anorexia, and has felt subjectively feverish, though she has not taken her temperature. Her last menstrual period was last week and had normal flow and timing, although 2 days shorter in duration than usual.

Physical findings;

T 101.0 F Oral, Pulse 100 Resp rate: 18 BP 128/80

Gen: appears ill but in no apparent distress

HEENT: moist oral mucosa

NECK: supple without mass, lymphadenopathy, or thyromegaly

LUNGS: clear to percussion and auscultation, with normal chest wall motion

HEART: RRR w/o M/G/R

ABD: Bowel sounds positive, Right lower quadrant tenderness without involuntary guarding and with rebound tenderness

Pelvic: External genitalia normal, no vaginal discharge or bleeding, cervix appears normal, Right adnexal tenderness on bimanual exam, normal sized uterus, nontender left adnexa

Rectal exam: tenderness right superior aspect of rectum

At this point in your evaluation, which of the following should be your two top diagnoses on the differential?

Choices:

Appendicitis, Right tubo-ovarian abscess

Appendicitis, diverticulitis

Ectopic pregnancy, Tubo-ovarian abscess

Cholecystitis, retro-cecal appendicitis

Answer 3

Appendicitis, Right tubo-ovarian abscess

Explanation:

• The best answer is Appendicitis, or tubo-ovarian abscess. At this point in the exam, it is difficult to tell between these two diagnoses. Imaging; ultrasound or CT scan might resolve the dilemma.
• Although diverticulitis can occur in the ascending colon presenting with right-sided pain, it is less likely than the typical left lower quadrant presentation.
• Ectopic preganancy is unlikely to present with fever, or in a patient who had a relatively normal period a week ago, however a pregnancy test would be essential in ruling out this possibility.
• Cholecystitis typically presents with right upper quadrant pain sometimes referred to the upper back or right shoulder.

Question 4

A 45-year-old woman develops cramping RUQ pain that is worse after meals. Each episode lasts about an hour. There is some nausea, and ocassional vomiting associated with these episodes. Which one of the following locations might be sites for pain that is referred?

Choices:

R shoulder

RLQ

LUQ

LLQ

Popliteal fossa

Answer 4

Right shoulder

Explanation:

Gall bladder disease can refer pain to the right shoulder.

Question 5

A 75-year-old man presents to the Emergency Department with severe (10/10) abdominal pain, radiating to his back over the past hour. He is unable to give much history, because of his pain. He denies hematemesis, hematochezia, vomiting or diarrhea. Social History is remarkable for smoking 1 pack/day of cigarettes for 40 years.

VS: T 98.6 F oral, Pulse: 140 beats/min, Respiratory Rate: 22 breaths/min; BP: systolic palpated at 50 mmHg

GEN: agitated, writhing in pain, pale, diaphoretic

HEENT: normal

NECK: supple

LUNGS: clear to percussion and auscultation

HEART: Regular rhythm, tachycardic to 140 beats/min, no M/G/R

ABD: Absent bowel sounds. Diffuse tenderness with voluntary guarding. Unable to assess rebound.

Which of the following should be at the top of your differential at this point?

Choices:

Leaking aortic aneurysm

Mesenteric artery thrombosis

Perforated peptic ulcer

Acute cholecystitis

Ruptured diverticulitis

Answer 5

Leaking aortic aneurysm

Explanation:

• The correct answer is leaking abdominal aortic aneurysm (AAA).
• Both mesenteric artery thrombosus and ischemia, as well as perforated peptic ulcer, should be on your list, but the AAA should take precedence because of the emergent nature of the presentation, and mortality risk. The patient’s tachycardia (more than one would expect from just pain), in addition to his hypotension and pallor, all point to blood loss. His quiet abdomen suggests blood has leaked into the abdominal cavity; blood is irritating, and this irritation causes ileus.
• All of these findings could be due to a perforated peptic ulcer, especially if there is the perforation has caused arterial bleeding, but the presentation favors an AAA. Either way, a rapid surgical assessment, with imaging if possible, and an emergent trip to the OR is indicated for this patient.
• Acute cholecystitis; typically presents in a less dramatic fashion, with RUQ pain, nausea, often bilious vomiting, and a positive Murphy’s sign.
• A ruptured diverticulum can present with an acute abdomen, but one would typically expect fever, several days of abdominal pain typically in the LLQ, and. unless septic, no hypotension or tachycardia.

Question 6

An 18-year-old man presents with right lower quadrant pain, and fever for 24 hours.

Physical exam reveals present bowel sounds, with tenderness over McBurney’s point. He has rebound tenderness, and increased pain in the right lower quadrant (RLQ) when flexing the right hip. Which of the following terms describes the manuever of flexing the hip to cause increased pain in the RLQ?

Choices:

Psoas sign

Obturator sign

Murphy’s sign

McBurney’s sign

Answer 6

Psoas sign

Explanation:

Correct Answer: –Psoas sign

• RLQ pain with right hip flexion
• Implies irritation of the psoas muscle, and perhaps a retrocecal appendix