A Cute Abdomen 🥹
A 21-year-old man has 12 hours of vague periumbilical abdominal pain that has migrated to the right lower quadrant. He has anorexia, nausea, and focal tenderness at McBurney point.
What is Acute Appendicitis?
A 42-year-old woman presents with RUQ pain after eating a fatty meal. Ultrasound demonstrates gallstones without gallbladder wall thickening or pericholecystic fluid.
What is the diagnosis?
What is Biliary Colic?
A trauma patient arrives hypotensive after a motor vehicle collision. FAST examination demonstrates free intraperitoneal fluid.
What is the next step?
What is Emergency Exploratory Laparotomy?
A patient develops oliguria after major abdominal surgery. His blood pressure is 85/50 mmHg and his heart rate is 120/min.
What is the most appropriate initial intervention?
What is IV Fluids?
A 23-year-old woman presents with a 2-cm, painless, mobile breast mass. The mass is firm and well-circumscribed. There are no skin changes or lymphadenopathy.
What is the most likely diagnosis?
What is Fibroadenoma?
A 42-year-old woman is found to have a thyroid nodule on physical examination. Her TSH is normal.
What is the next step in evaluation?
What is Thyroid Ultrasound?
A hemodynamically stable patient has suspected acute appendicitis.
What imaging study is generally preferred in a nonpregnant adult?
A 58-year-old woman presents with crampy abdominal pain, vomiting, abdominal distention, and obstipation. She underwent a hysterectomy 10 years ago. CT shows dilated small-bowel loops with a transition point.
What is the most likely cause?
What is Postoperative Adhesions?
BONUS ($100): What is the most common cause of an SBO in a patient with no previous abdominal surgery?
A patient has fever, RUQ pain, leukocytosis, and a positive Murphy sign.
What is the definitive treatment for an otherwise healthy surgical candidate?
What is Early Laparoscopic Cholecystectomy (<48 hours)?
A 74-year-old man with a history of tobacco use presents with sudden-onset abdominal and back pain followed by syncope. He is pale and diaphoretic. His BP is 78/46 mmHg and HR is 128/min. A pulsatile abdominal mass is palpated.
A bedside ultrasound demonstrates a 7.5-cm infrarenal abdominal aortic aneurysm with free fluid in the abdomen.
What is the next best step?
What is Immediate Operative Repair of the Ruptured AAA?
A patient develops fever, tachycardia, abdominal pain, and leukocytosis on postoperative day 5 after colorectal surgery.
What complication should be strongly suspected?
What is Anastomotic Leak?
A 52-year-old woman presents with a new, firm, irregular breast mass. Mammography demonstrates a spiculated mass with associated architectural distortion.
What is the next best step?
What is Image-guided Core Needle Biopsy?
A 68-year-old man presents with a reducible, painless groin mass that becomes more prominent with coughing. On examination, the mass is located medial to the inferior epigastric vessels.
What type of hernia is this?
What is Direct Inguinal Hernia?
A patient with suspected acute cholecystitis has equivocal ultrasound findings but a strong clinical suspicion.
What study is most useful to evaluate cystic duct obstruction?
What is HIDA scan?
A 67-year-old man presents with LLQ abdominal pain, fever, and leukocytosis. CT demonstrates sigmoid diverticulitis with a 5-cm pericolic abscess.
What is the most appropriate management?
What is Percutaneous Drainage AND Antibiotics?
A patient presents with jaundice, fever, and RUQ pain. Laboratory testing demonstrates a cholestatic pattern, and ultrasound shows a dilated common bile duct.
What is the next best step?
What is Endoscopic Retrograde Cholangiopancreatography (ERCP)?
A patient with penetrating neck trauma develops expanding neck hematoma, stridor, and respiratory distress.
What is the next best step in management?
What is Intubation?
A postoperative patient develops sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia. CT angiography demonstrates a large pulmonary embolus. The patient is hypotensive despite initial resuscitation.
What is the appropriate definitive treatment if there is no contraindication?
What is Systemic Anticoagulation?
A 61-year-old woman has a 2.5-cm invasive ductal carcinoma of the breast. Biopsy demonstrates estrogen receptor-positive, HER2-negative disease. There is no clinical evidence of distant metastasis.
She undergoes breast-conserving surgery with negative margins.
Which additional procedure is generally appropriate for axillary staging?
What is Sentinel Lymph Node Biopsy?
A 57-year-old woman has a thyroid nodule. FNA demonstrates papillary thyroid carcinoma.
Which lymph node compartment is most commonly involved?
What is Central Cervical Lymph Nodes?
A patient has a symptomatic reducible inguinal hernia.
What is the definitive treatment for an appropriate operative candidate?
What is Elective Surgical Repair?
A 71-year-old woman with atrial fibrillation presents with sudden, severe abdominal pain that began 4 hours ago. She is nauseated but has had no vomiting.
HR is 112/min, BP is 134/78 mmHg, and lactate is 2.9 mmol/L. Her abdomen is soft with only mild diffuse tenderness.
What is the most appropriate diagnostic study?
What is CT Angiography of the Abdomen?
A 55-year-old man has progressive painless jaundice, weight loss, and a palpable nontender gallbladder.
What is the most likely diagnosis?
What is Pancreatic Adenocarcinoma?
A 32-year-old man is brought to the trauma bay after a stab wound to the left chest. He is awake but increasingly anxious. His heart rate is 128/min, blood pressure is 86/58 mmHg, and oxygen saturation is 96% on room air. His neck veins are distended, but breath sounds are present and equal bilaterally.
FAST examination demonstrates a large pericardial effusion with right ventricular diastolic collapse.
What is the most appropriate next step?
What is Emergency Thoracotomy/Sternotomy?
A patient receiving total parenteral nutrition develops weakness, confusion, edema, and cardiac dysfunction shortly after nutrition is initiated following prolonged starvation.
Which electrolyte abnormality is most likely responsible?
What is hypophosphatemia?
A 46-year-old woman has bloody nipple discharge from a single breast duct. Diagnostic imaging identifies a small retroareolar lesion. Core biopsy demonstrates an intraductal papilloma with atypia.
What is the appropriate management?
What is Surgical Excision?
A 48-year-old woman has recurrent nephrolithiasis, constipation, fatigue, and bone pain. Laboratory studies show:
What is the most likely diagnosis?
What is Primary Hyperparathyroidism due to Parathyroid Adenoma (most likely)?
BONUS ($200): What is the treatment for this patient?
A patient with suspected esophageal perforation is hemodynamically stable.
What imaging modality is useful for diagnosis?
What is CT chest with water-soluble oral contrast (gastrografin) / CT esophagography?
A 68-year-old woman with a history of multiple abdominal surgeries presents with severe abdominal pain, tachycardia, and vomiting. CT demonstrates a closed-loop small-bowel obstruction with pneumatosis intestinalis and free fluid. She develops hypotension despite fluid resuscitation.
What is the next best step?
What is Emergency Exploratory Laparotomy?
A 61-year-old woman presents with severe epigastric pain radiating to the back. Lipase is markedly elevated. She becomes hypotensive and develops hypoxemia. CT demonstrates pancreatic necrosis.
What is the initial management?
What is Aggressive Support with IV Fluids, Analgesia, Nutritional Support, and Treatment of Organ Dysfunction PRN?
A 65-year-old man with peripheral arterial disease develops sudden onset leg pain. The extremity is cold, pale, pulseless, and has decreased sensation.
What is the immediate initial treatment?
What is IV Unfractionated Heparin while waiting for revascularization?
A patient becomes febrile 24 hours after surgery. He is otherwise stable and has no localizing symptoms.
What is the most appropriate initial approach?
What is Clinical Evaluation? (rather than automatically ordering a broad infectious workup)
A 55-year-old woman undergoes stereotactic biopsy for microcalcifications. Pathology demonstrates atypical ductal hyperplasia.
What is the major concern that drives management?
What is Risk of Upgrade to Ductal Carcinoma in situ or Invasive Carcinoma?
A 45-year-old woman presents with episodic headaches, palpitations, diaphoresis, and severe hypertension. A CT scan demonstrates a 4-cm adrenal mass. Plasma metanephrines are positive.
What is the next best step in management?
What is Alpha adrenergic blockade BEFORE Beta blockade?
A 70-year-old patient develops fever, tachycardia, hypotension, abdominal pain, and rising lactate after colorectal surgery. CT demonstrates free intraperitoneal air and fluid with concern for an anastomotic leak.
What is the most appropriate next step?
What is Emergent Operative Exploration/Source Control?