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100
24 year old G1P0 woman presents to the emergency room with abdominal pain for past 6 hours. Pain is located in the RLQ, described as 8/10, stabbing. Associated with N/V, fever. Physical exam reports RLQ with right hip flexion and internal rotation. What is the best initial imaging test for this patient's condition?
What is: Ultrasound
Appendicitis: In pregnancy women U/S is best initial choice to avoid rdaiation, otherwise best choice is CT scan
100
45 year old male presents to clinic for black stools for past 2 days. He reports intermittent epigastric pain that is worse with food intake. Pain occasionally improves with antacids. He takes a stool antigen test that comes back positive for H.Pylori. What is the treatment?
Standard triple therapy: PPI, amoxicillin 1g, clarithromycin 500mg for 7-10 days, up to 14 days
Test of cure should be done for all patients after therapy, two weeks after finishing treatment, via breath or stool test
100
B/L renal stones
200
42 year old female presents with abdominal pain. PMHx of HLD and DM. She is febrile, tachycardic, hypotensive, and you notice scleral icterus, tender to palpation of RUQ. Her WBC is elevated, ALP is elevated. What is the best initial diagnostic imaging for this condition?
Ultrasound
Cholangitis: Charcot triad: jaundice, fever, RUQ, hypotension, AMS
200
50 year old male presents to the ED with acute onset epigastric pain. His PMHx: HLD, DM, alcohol abuse. His last drink was this morning and he drinks 20 beers a day. +N/V, nonbloody, nonbilious, physical exam reveals tenderness to palpation of the epigastrium, and lab is positive for lipase of 230. What is your treatment for this patient?
Hydration at a rate of 5 to 10 mL/kg per hour of isotonic crystalloid solution. In patients with severe volume depletion that manifests as hypotension and tachycardia, we provide more rapid repletion with 20 mL/kg of intravenous fluid given over 30 minutes followed by 3 mL/kg/hour for 8 to 12 hours. Adequate fluid replacement can be assessed by an improvement in vital signs (goal heart rate <120 beats/minute, mean arterial pressure between 65 to 85 mmHg), urine output (>0.5 to 1 cc/kg/hour) and reduction in hematocrit (goal 35 to 44 percent) and BUN over 24 hours.
Pain control with hydromorphone
Advance diet as soon as patient tolerates it, To maintain gut barrier function and prevent early bacterial translocation, enteral feeding > parenteral feeds
200
Free air under diaphragm, possibly due to perforated peptic ulcer
300
A 53 year old woman presents to ED with recurrent N/V for past 3.5 weeks. On average these episodes occur after food intake. She occasionally feels as if she is more full with only eating a small amount and feels bloated a lot. PMHx is poorly controlled DM for past8 years. On physical exam she is afebrile, normotensive, RR is 18, HR is 80, has some mild epigastric tenderness to palpation. What diagnostic study will confirm her diagnosis?
gastric emptying scintigraphy
Gastroparesis: Syndrome of delayed gastric emptying in the absence of mechanical obstruction caused by abnormalities of antral motor function and coordination and postprandial gastric contraction/reduced contraction, most commonly associated with people who have diabetes, who are poorly controlled. Tx: diet controlled by avoiding fatty/spicy foods and optimizing glycemic control, can try metoclopramide and prochlorperazine for antiemetics
300
45 year old man with HTN and obesity presents with complaints of heartburn and regurgitation with a sour taste in his mouth. He states he likes to drink at least 3 cups of coffee a day. He endorses intermittent night time coughing especially when he eats dinner at 8-9pm. What treatment can help relieve his symptoms?
Lifestyle modifications: elevate bet, decrease smoking, decrease fat intake, avoid eating right before bedtime.
antacids --> H2 blockers: Famotidine 20mg BID, Ranitidine 150mg BID
PPI: Omeprazole 20mg daily, pantoprazole 40mg daily
300
Pancreatitis
400
50 year old man presented to the ED with acute onset of abdominal pain. He has PMHx of HTN, DM, and alcohol abuse. He states he drinks about 10 beers a day every day. He also reports N/V. He is hypotensive, HR 98, RR 18, afebrile, his epigastric region is tender to palpation. What further workup can help confirm this patient's diagnosis?
Elevated lipase or CT scan suggestive of pancreatitis
- diagnosis by 2 or more of the following
- acute-onset epigastric pain
- ↑ serum amylase or lipase to 3x upper limit of normal
- imaging suggestive of pancreatitis
400
18 year old female presents with on going severe crampy abdominal pain, associated with nonbloody diarrhea for past couple weeks and noticed some weight loss. On physical exam you notice sores on her bucca mucosal. Her lab results were significant for positive fecal calprotectin. She states she had a recent colonoscopy done which showed cobble-stoning and skip lesions. What is the preferred treatment for this patient?
Corticosteroids 40-60mg daily for flares, Depending on response and how quickly remission is achieved, first tapering by 5 mg per week until the patient reaches a dose of 20 mg, and then tapering by 2.5 to 5 mg weekly until discontinuation is an appropriate strategy.
Adalimumab (anti-TNF agents): check for TB prior
Budesonide treatment for inducing remission in low-risk patients with mildly active Crohn disease of iluem/proximal colon, start at 9mg for at least 4 weeks, taper by 3mg every 2-4weeks
Azathioprine/methotrexate are reserved for patients with severe disease, not used as monotherapy, often used with infliximab/humira
400
Sigmoid Diverticulitis
500
A 68 year old female is brought to the ER this morning for severe abdominal pain since yesterday afternoon. She reports pain 9/10, located in LLQ. She pain is associated with N/V. Patient is afebrile. Physical exam reveals abdominal tenderness in LLQ and voluntary guarding and rigidity. What is the test of choice for this patient?
CT scan with oral and IV contrast
Diverticulitis: Factors associated with diverticulosis include alterations in colonic wall resistance, colonic motility, and dietary issues, such as lack of fiber, that contribute to increased intraluminal pressure and weakness of the bowel wall.
CT findings: Free air, bowel wall thickening, fat stranding, abscess
*Colonoscopy is contraindicated in acute diverticulitis
500
A 65 year old man is brought to the ED for abdominal pain. He was found drunk and pass out on the street. When presenting to the ED he was altered and was not oriented to time/place. He reports drinking a couple glasses of whiskey a day for the past 10 years. On exam his abdomen is very distended and there is a positive fluid wave. Patient's ammonia levels were 103. Best management of this patient's condition?
500
Constipation