Abdominal Pain

Question 1

Radiographic finding highly sensitive for mesenteric ischemia/infarction

Answer 1

Pneumatosis intestinalis

Question 2

Metabolic abnormalities seen in alcoholic ketoacidosis

Answer 2

Elevated serum ketones (B-OH:AcAc ratio ~5:1, consequently nitroprusside test may only be weakly positive because it only reacts with AcAc), high anion gap and metabolic alkalosis from vomiting.

Question 3

Treatment of alcoholic ketoacidosis

Answer 3

1) Give thiamine to prevent Wernicke’s encephalopathy. #2) D5NS or D5 1/2NS + carbohydrates to suppress counter-regulatory hormone release, decrease ketogenesis and normalize NADH/NAD+ ratio.

Question 4

Calculate anion gap

Answer 4

Na - Cl - HCO3

Question 5

Initial treatment of a patient with suspected renal calculi

Answer 5

IVF, anti-emetic, NSAID (decreases ureteral spasms and renal capsular pressure)

Question 6

Mnemonic for causes of small bowel obstruction

Answer 6

ABC: Adhesions, bulges (hernia) and cancer

Question 7

When should you start antibiotics for spontaneous bacterial peritonitis? Which abx are indicated?

Answer 7

Paracentesis shows neutrophil count > 250. Abx that cover common organisms (E. coli, Klebsiella and Streptococci) are 3rd gen cephalosporins.

Question 8

Prehn sign

Answer 8

Physical elevation of testicle relieves pain in epididymitis, not in testicular torsion.

Question 9

Which way do you spin the testicle to detorse it?

Answer 9

Laterally “like opening a book”

Question 10

Lab findings in patients with appendicitis

Answer 10

WBC > 10k in 90%, may also have +LE in urine due to irritation of ureter and pyruia.

Question 11

Initial test for patients with suspected ovarian torsion

Answer 11

Doppler ultrasound

Question 12

Charcot’s triad

Answer 12

RUQ pain, jaundice and fever indicative of cholangitis

Question 13

Plain film findings in patients with AAA

Answer 13

Curvilinear calcification of the aortic wall or paravertebral soft tissue mass

Question 14

Ranson’s criteria at admission

Answer 14

“GA LAW”: Glc > 200, Age > 55, LDH > 350, AST > 250, WBC > 16. Each + criteria gets 1 point and mortality goes up with each point. 0-2 = 2%, 3-4 = 15%, 5-6 = 40%, > 6 = 100%. BISAP score is newer and probably better

Question 15

Ranson’s criteria 48 hours after admission

Answer 15

“CHOBBS”: Ca < 8, > 10% Hct drop, pO2 < 60mmHg, Base deficit (24 - HCO3) > 4, BUN increase > 4, Sequestration ( > 6L fluid requirement). Each + criteria gets 1 point and mortality goes up with each point. 0-2 = 2%, 3-4 = 15%, 5-6 = 40%, > 6 = 100%.

Question 16

Causes of epididymitis

Answer 16

E. coli in men > 35 (prostatitis, catheterization). N. gonorrhoeae and C. trachomatis in men < 35.

Question 17

Treatment of urethritis in men

Answer 17

50% will be due to coinfection with N. gonorrhoeae (ceftriaxone or ciprofloxacin x1) and C. trachomatis (azithromycin x 1 or erythromycin x 7d or doxy x 7d).

Question 18

Diverticular abscess size that can be treated with antibiotics alone? Which abx?

Answer 18

5cm or less. Tx w/cipro and metronidazole

Question 19

Blumberg sign

Answer 19

Rebound tenderness over McBurney’s point

Question 20

Initial management of SBO

Answer 20

NG decompression, IV fluids, surgical consultation and IV antibiotics if surgery is planned

Question 21

Who should be admitted for treatment of PID

Answer 21

Pregnant, failed on outpatient abx, unstable, TOA or cannot rule out surgical condition.

Question 22

How can you tell an obstruction int the small bowel from one in the large bowel?

Answer 22

Small bowel has valvulae convientes, which are similar to haustra of the large bowel; however, the cross the entire width of the small bowel, unlike haustra.

Question 23

Next step in a patient with dislodged G-tube

Answer 23

Try to replace it, if you meet resistance, stop. If you don’t, then advance, inject 30-50cc of water soluble contrast and take a supine plain film. If you can visualize gastric rugae, the patient may begin feeding.

Question 24

Next step in patients with obstructing uretral calculus + overlying infection.

Answer 24

IV abx + urgent surgery. This can progress to abscess and necrosis of the kidney if not cleared.

Question 25

Size of ureteral calculi and likelihood of passage without intervention

Answer 25

< 4mm = 90%. 4-6mm = 50%. >6mm = 10%.

Question 26

Treatment of scromboid fish poisoning

Answer 26

Eating the dark fish meat results in histamine-like reaction in 20-30 minutes and can adequately be treated with antihistamines.

Question 27

Most common cause of food outbreaks in the US.

Answer 27

C. perfringens from undercooked poultry and beef

Question 28

Suspected etiology of mesenteric ischemia in patients with sudden onset pain vs. insidious onset pain?

Answer 28

Sudden = arterial embolism. Insidious = venous thrombus.

Question 29

Prophylactic medications given to sexual assault victims in the ED

Answer 29

Ceftriaxone (gonrrhea), azithromycin (chlamydia), metronidazole (syphilis and trichomoniasis), +/- antiretrovirals for post-exposure prophy, emergent contraception, tetanus if injured and HBV if unvaccinated.

Question 30

Extra-intestinal manifestations of IBD. What is one that is seen in Crohn's but not UC?

Answer 30

Aphthous ulcers, erythema nodosum, iritis or episcleritis, arthritis, and gallstones. Nephrolithiasis is only seen in Crohn's due to ileal inflammation, increased oxalate absorption and formation of oxalate stones.