Q

Question 1

A 22-year-old man comes to the emergency department with a persistent, painful erection he has had for the past 6 hours.
The patient has had similar episodes that lasted 1-2 hours but resolved spontaneously. He says his symptoms started this morning without provocation when he woke up. The patient recently started a summer job working outside pouring concrete.
Medical history includes sickle cell disease; he has not taken any medications other than his usual folic acid. The patient does not use alcohol or illicit drugs. On examination, the penis is rigid, and the glans is soft. The scrotum is normal. Which of the following is the most appropriate next step in management? **other management **
O A. Administer a packed red blood cell transfusion
O B. Administer an intravenous beta blocker
O C. Administer-sublingual-nitroglyeerin
O D. Aspirate blood from the corpora cavernosa
O E. Insert a urinary catheter

Answer 1

Aspirate blood from the corpora cavernosa and sympathomimetic drug (like phenylephrine ) to contract cavernous muscle

Causes in scd- dehydration as in this patient, cold alcohol fever

Ep

Question 2

A 25-year-old man is brought to the emergency department after a syncopal event. His wife reports that they were resting in bed, watching television together, when he suddenly passed out. The patient was unconscious for approximately a minute, during which time there were a few bilateral jerks of the arms and legs. He has never had a similar episode but recently noticed some palpitations at night. The patient has no chronic medical conditions but had a fever as high as 38.3 C (100.9 F along with a mild cough and body aches, throughout the day. Family history is significant for a male cousin who died unexpectedly in his sleep at age 37. Temperature is 38 C (100.4 F), blood pressure is 128/76 mm Hg, and pulse is 98/min, The patient is awake and alert and in no distress. The pupils are equal and reactive to light. The oropharynx is normal.
Breath sounds are normal. No heart murmurs are heard. The extremities are well perfused, with symmetric strength.
Influenza test is positive. Which of the following is the most likely cause of this patient’s syncopal episode?
A rapi
O A. Febrile seizure
O B. Hypertrophie-eardiemyopathy
O C. Orthestatie-hypotension [1%]
O D. Vasevagal-syncepe
O E. Ventrioular-tachyeardia

Answer 2

E. Ventricular tachycardia (Brugada) - triggered by fever and high temp changes the na current in heart

Cardiac syncope due to an arrythmia
- warning signs ——sudden onset without warning symptoms indicates a tachareythmia, occurring at rest which wouldn’t happen with vasovagal or orthostatic, recent palpitations indicates transient arrythmia , sudden death in young family member indicates inherited cardiac conductive syndrome that leads to an ventricular tachycardia (long

Question 3

Management of primary dysmenorrhea
- sexually active vs non

Answer 3

Non- NSAIDs decreases prostaglandins
Active- OCP

Question 4

38-year-old woman comes to the office due to abdominal bloating, excessive flatulence, and diarrhea over the past 3 onths. She has 4 or 5 honbloody, loose stools a day, including at night. The patient has a history of obesity and lost 30 kg ; Ib) after undergoing Roux-en-Y gastric bypass surgery 3 years ago. She takes multiple vitamin supplements daily but ha taken antibiotics recently. The patient has not traveled recently or been exposed to anyone with diarrheal illness! sperature is 37 C (98.6 F), blood pressure is 130/84 mm Hg, and pulse is 78/min. BMI is 28 kg/m°. Abdominal mination shows no abnormalities. Which of the following is the most likely cause of this patient’s symptoms? (Rf, management)
A. Bacterial overgrowth
B. Clostridioides diffieile-infectien
C. Dumping-syndrome
D. Irritable bowel syndrome
E. Stomal obstruction

Answer 4

A. Bacterial overgrowth ( small intestinal bacterial overgrowth aka SIBO)

SIBO
- RF: ileocecal removed(so bacteria can enter si)gastric bypass bc blind loop of intestines therefore bacteria can grow ,
Anatomical abnormalities(strictures, surgery, diverticulosis), motility disorders(scleroderma, opioid use and DM), immunodeficiency, chronic pancreatitis , gastric hypochlorydia and PPI use

Symptoms- flatulence, chronic watery diarrhea , bloating , and maybe malabsorption of fat soluble vitamins and Vit b12bc bacterial consumes it) inc folate and Vit k which are produced by the bacteria

Management:
Dx: carbohydrate breath test (lactulose or glucose) to measure hydrogen or methane produced by the bacteria)- if colonic bacteria breaks down no absorbed substrate before 2-3 hours causing rise in breath hydrogen indicates SIBO
2) invasive endoscopy of jejunal aspirate and culture

Tx: empiric antibiotics(rifaximin)

Question 5

Management of primary polydipsia and inspidus
- cause of di in a child

Answer 5

Water deprivation test or Desmopressin( in kids to avoid hypernatremia)
- primary- adh is inhibited bc of increased water intake. Water deprivation then increases adh and urine becomes concentrated
- inspidus: when doing the test the urine remains dilate

Hereditary nephrogen diabetes inspidus is most common cause when mentioning familial polyuria or polydipsia

Question 6

Tuberous sclerosis
- pathophysiology
- MOI
- symptoms
- surveillance

Answer 6

Tuberous sclerosis complex
• Mutation (inherited or de novo) in TSC1 or TSC2 gene leads to benign tumors
• Autosomal dominant

• Dermatologic
• Ash-leaf spots (light)
• Angiofibromas of the malar region
• Shagreen patches (textured skin )

• Neurologic
Clinical features
• CNS lesions (eg, subependymal tumors)
• Epilepsy (eg, infantile spasms)
• Intellectual disability
• Autism & behavioral disorders (eg, hyperactivity)

• Cardiovascular: rhabdomyomas (asymptomatic or cause murmurs, arrythmia or heart failure ) ; present large by regresses on its own in infancy

• Renal: angiomyolipomas
• Tumor screening
• Regular skin & eye examinations
• Serial MRI of the brain & kidney
Surveillance
• Baseline echocardiography & serial ECG
Baseline electroencephalography
• Neuropsychiatric screening

Question 7

NF1
- MOI
- symptoms

Answer 7

AD
HYPERPIGMENTED cafe au lait, optic gliomas, freckling of axillary and inguinal, scoliosis, neurofibromas , pseudoarthrosis , seizures and ID

Question 8

Endometriosis vs adenomyosis symptoms

Answer 8

Both have chronic pelvic pain and dysmenorrhea but uterus findings are different
- a - endometrial gland accumulation causes a diffusely symmetric (globular enlargement by endometriosis the uterus is non tender and small

Question 9

Post exposure prophylaxis after sexual assault

Answer 9

Doxy, ceft and metronidazole against trich and chlam/gonorrhea

Question 10

A 16-year-old boy is brought to the office due to right knee swelling. He first noticed it after soccer practice a few days ago but does not recall injuring the knee. The joint feels stiff and is not painful. The patient spent the summer at a soccer camp r Maine. He is sexually active with his girlfriend and uses condoms. Vital signs are normal. The patient can bear weight and has a grossly normal gait. Examination of the right knee shows palpable warmth and a large effusion. It is minimally tender to palpation. Range-of-motion testing shows decreased flexion of the right knee compared with the left. All other joints are normal. Plain radiographs reveal no bony deformity. Aspiration yields yellow, translucent fluid with a leukocyte count of 15,000/mm’ (50% heutrophils) and no organisms on Gram stain. Which of the following is the most likely cause of this patient’s knee swelling? (**symptoms , diagnostic and treatment **
A. Borrelia burgdorferi infection
B. Disseminated-gonococcal infection
C. Prior Chlamydia trachomatis infection
D. Prior streptococcal throat infection
O E. Staphylococcal joint infection

Answer 10

Lyme
Minnesota and Wisconsin included

Early localized
(days to 1 month)

Erythema migrañs
Fatigue, headache
Myalgia, arthralgia

Early disseminated

Multiple erythema migrans

• Unilateral/bilateral cranial nerve palsy (eg. CN VII)
(weeks to months)
• Meningitis
Carditis (eg, AV block)
• Migratory arthralgia

Late
(months to years)

Arthritis( oligoarticular)
• Encephalitis
Peripheral neuropathy

Diagnosic
Synovial fluid analysis - 10k- 25K leukocyte with negative gram stain and culture
- enzyme immunoassorbwnt assay and western blot for confirmation

Tx: oral doxycycline

Question 11

Synovial fluid analysis
- Lyme disease
- gonorrhea
- staphylococcal

Answer 11

Lyme - 10K-25K leukocyte (50% neutrophils with neg gram stain and culture; no systemic symptoms, acute monoatticular; minimally painful

Gonorrhea- acute a febrile oligoarticular or chronic polyartiuclar ; painful
>25K leukocyte and a lot of neutrophils and May or May not have positive gram stain

StaphyloccoL - painful ; leukocyte >50K and positive gram stain

Question 12

5-year-old woman comes to the office due to insomnia and fatigue that began shortly after her divorce was finalized a year The patient used to sleep 7-8 hours without difficulty; however, over the past year she has had increasing difficulty falling ep and started drinking 2-3 glasses of wine before bedtime to help. Despite falling asleep more quickly, she has recently ad to regularly wake up around 3:00 AM. Her symptoms have progressively worsened and she now lies awake for al hours in the middle of the night, thinking and worrying about her future, but she rarely experiences anxiety during the She reports mild difficulty with concentration and no change in appetite. The patient experiences occasional brief ss and lonelihess. She has recently started showing up late for work and has stopped attending her weekly exercise Medical history includes hypothyroidism, treated with levothyroxine, and gastrosophageal reflux disease, diagnosed 3 ago and treated with famotidine. Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 90/min, and ons are 12/min. Physical examination shows a mild tremor but no other abnormalities. Laboratory results are as

Hgb 11.4
Mean corpuscular 106
Blood urea nitrogen 20
Creatinine normal
AST 85
Alt 42

Which of the following is the most likely diagnosis in this patient?
O A. Adjustment disorder [5%

O B. Alcohol use disorder
C. Anxiety disorder due to another medical condition
O D. Generalized anxiety disorder
O E. Insomnia disorder
O F. Persistent depressive-diserder (elysthymie)

Answer 12

Alcohol use disorder
->65 : >7 drinks in a week or >3 in a day (men less than 65 >14 drinks in a week or >4 drinks in a day
- 14 drinks per week , AST:ALT 2:1, tremors, macrocytosis, tardiness, impaired functioning, recent diagnosis with GERD AND HTN, sleep disturbance and anxiety (usually sell help for this first this indicates withdrawal

Question 13

Anterior uveitis causes

Answer 13

Herpes, todo
Sarcoidosis
Spondyliarthriirs
IBD

Question 14

Diagnostic for carotid artery dissection

Answer 14

CT or MR angiography

Question 15

Initial diagnostic test for Cushing

Answer 15

Overnight Low dose dexa suppression
24 hour urinary free cortisol
Late night salivary cortisol
- 2 needs to be abnormal so do two

Question 16

Abnormal jerk movements that disappear during sleep in a 12 year old girl
- pathophysiology
- symptoms
/ diagnostic
- treatment
- prognosis

Answer 16

antistreptococal antibodies cross react with host neuronal antigens in the basal ganglia months after GAS infection

Sydenham chorea - irregular movements , hypotonia, behavioral changes (OC behaviors etc )

Diagnostic - GAS throat culture (usually negative) and ASO and anti Dnase B títere (usually still positive y months after initial infection

• cardiac testing : ECHO and EKG to test for rheumatic fever

Tx: chronic antibiotics (like penicillin or if symptomatic (antidopaminergic like haldol

Prognosis - chorea self resolves in a few months but the psych symptoms waxed and wane; recurrence is common

Question 17

A 34-year-old man comes to the emergency department for right upper quadrant abdominal pain. The pain started abruptly 24 hours ago and is described as constant, severe, and progressive. The patient was hospitalized 6 months ago for similar symptoms that were resolved with antibiotics. Review of systems is positive for occasional bloody stools. There is no elevant family history, and the patient does not use tobacco, alcohol, or illicit drugs. Temperature is 39.8 C (103.6 F), blood essure is 90/50, pulse is 120/min, and respirations are 22/min. The patient is lethargic and difficult to arouse. Scleral erus is present. Cardiopulmonary examination is unremarkable. The abdomen is tender to palpation in the right upper drant. Laboratory evaluation reveals the following:

Plt and wbc high
Total bili 6.2
Alk 853
AST alt 108 142

Leukocyte
17,200/mm
Liver function studies
Total bilirubin
6.2 mg/dL.
Alkaline phosphatase
854 U/L
Aspartate aminotransférase (SGOT) 108 U/L
Alanine aminotransferase (SGPT)
142 U/L
Lipase
20 U/L
Right upper quadrant ultrasound is normal. Which of the following is the most likely cause of this patient’s presentation? (management
O A
Annular-pancreas
O B. Cholangiocarcineme
O C. Chrenie-panereatitis
O D. Pancreatic divisum
O E. Primary-biliary-cholangitie
O F. Primary sclerosing cholangitis

Answer 17

PSC
- associated with Uc ,
- causes stricjre and fibrosis of the Intra and extrahepatic bile ducts . Strictures cause obstruction therefore bacterial invades leading to acute cholangitis (Pentad noted)

Management
- endoscopic interventions for strictures
- therapy for Uc (hematochezia see )
- antibiotics for cholangitis
- maybe urseodeoxycolic acid

Question 18

Management of Bartholin cyst

Answer 18

Observation and expectant management

But if symptomatic ID and word catheter

Question 19

A 57-year-old woman comes to the office for evaluation of vaginal pruritus, pain with urination, and increased urinary frequency. The patient’s symptoms have been present for several iths but have intensified recently.
Her husband passed
away 4 years ago, and the patient had not been sexually active until 6 months ago with a new partner. She has had some pain with intercourse and has tried over-the counter, water-based tubricants with little relief. Her last menstrual period was 7 years ago. She has poorly controlled type 2 diabetes mellitus with a recênt hemoglobin A1c of 8.4%. BMI is 28 kg/m?. Vital signs are normal. Pelvic examination shows thin vulvar skin with reduced elasticity. The vagina appears pale, dry, and had multiple areas of petechiae. There is minimal clear discharge in the vault.
Vaginal pH is 6.5.
Urinalysis is normal. Which of
the following is the best next step in management of this patient? management
A. Oral metronidazole
O . Oral nitrofurantoin
O C. Topical corticosteroid cream
O D. Topical nystatin cream
VO E. Vaginal estrogen cream

Answer 19

Vaginal estrogen cream- genitourinario syndrome of menopause

This patient has genitourinary syndrome of menopause (or atrophic vaginitis), in which reduced estrogen levels associated with menopause cause decreased blood flow and reduced collagen and glycogen content in vulvovaginal tissues This results in thin vulvar skin with reduced elasticity and loss of vaginal tissue pliability that cause vaginal pruritus and dyspareunia. Due to the proximity of the bladder to the vaginal epithelium, the bladder trigone and urethral epithelium mar also atrophy, resulting in dysuria and urinary frequency (mimicking a urinary tract infection). Patients typically have a pale, vagina with petechia (due to easily denuded epithelium) and minimal vaginal discharge with a pH >4.5 (due to decrea lactic acid production from low glycogen content)
The first-line management of atrophic vaginitis is vaginal moisturizers and lubricants. In patients with no symptom improvement, treatment is with vaginal estrogen (eg, cream, tablet, ring), which increases blood flow and glycogen cor to the vulvovaginal tissues.

Question 20

21/40
REVIEW
A 68-year-old man comes to the office for follow-up of an abnormal finding on abdominal CT scan. Two weeks ago, the patient was seen in the emergency department for left lower quadrant abdominal pain. CT scan revealed acute sigmoid diverticulitis, which improved with oral antibiotics, as well as a cyst in the head of the pancreas. The patient has no history of pancreatic diseases and reports no epigastric pain, diarrhea, or weight loss. He used to drink alcohol heavily but stopped several years ago and does not smoke cigarettes. Family history is unremarkable. Vital signs are within normal limits.
Physical examination shows no abnormalities. MRI of the abdomen confirms a 4.6-cm, multilocular cyst in the head of the pancreas with thickened walls. The main pancreatic duct is mildly dilated. Serum amylase, lipase, and liver chemistry studies are within normal limits. Which of the following is the next best step in management of this patient?

A. Endoscopic ultrasound-guided biopsy
B. Reassurance and no further intervention
C. Sereening-for-intraeranial-aneurysms
D. Serelegie-testing-for-intestinalhelminths
E. Surgieal drainage of the eyst

Answer 20

A. Endoscopic ultrasound-guided biopsy

• Large size (>= 3 cm)
• Solid components or calcifications
• Main pancreatic duct involvement (ie, ductal dilation)
Thickened or irregular cyst wall

Question 21

A 4-month-old boy is admitted to the intensive care unit due to respiratory distress. The infant developed cough and tachypnea 2 days ago and has had progressive difficulty breathing. He has also had 2 months of poor weight gain and diarrhea, which have not improved despite changing to a hydrolyzed formula. The patient lives with his foster parents.
The
biological mother did not receive prenatal care after the first trimester. Birth weight was at the 60th percentile, and current weight is at the 3rd percentile, Temperature is 39.5 C (103,1 F) and pulse oximetry is 74% on room air. Physical examinatior shows extensive oral thrush and generalized lymphadenopathy. Lung auscultation reveals bilateral crackles. The remainder of the examination is normal. The patient is intubated, and endotracheal tube aspirate is positive for Pneumocystis jiroveci Which of the following is the most likely underlying cause of this patient’s illness? (**diagnostic testing **
O A. Abnormal-chloride ion transporter
O B. Decreased CD4 lymphecyte count
C. Deficiency in adenosine deaminase
O D. Low-levels-of all immuneglebulins
O E. Reduced-phagecytotio-activity

Answer 21

B. HIV not SCID due to the lymphadenopathy

Diagnostic - HIV DNA or RNA PCR and not antibodies if <18 months because moms antibodies can be false positive

Question 22

Psychogenic no epileptic seizures
- management (diagnostic and treatment?

Answer 22

Dx: Video EEG
Tx: CBT and neurologic follow up

Question 23

A 36-year-old primigravid woman at 34 weeks gestation arrives at the emergency department after being found unresponsive on the floor by her husband. She was found unconscious about 30 minutes ago and became gradually responsive over a few minutes. The husband reports the patient has had increasing nausea and vomiting over the past few hours and a severe frontal headache. Currently she has no symptoms other than the headache. Medical history is significant for migraines, and he patient takes no daily medications. Temperature is 36.7 C (98.1 F), blood pressure is 138/98 mm Hg, pulse is 78/min, and spirations are 20/min. Cranial nerves are intact, and the neck is supple. Funduscopic examination is normal. The lungs e clear to auscultation bilaterally. Cardiac examination demonstrates normal heart sounds. The abdomen is nontender, and uterine fundus measures 34 weeks gestation. There is minimal pretibial edema, and deep tendon reflexes are 3+. Motor mination is normal. Laboratory results are as follows:

All normal except UA showed ketones

Urine drug screen is negative. CT scan of the head reveals bilateral frontal lobe edema but no mass lesions or bleeding.
Which of the following is the best next step in management of this patient?
A. CT venography
O B. Lumbar puncture
O C. Magnesium sulfate infusion

Answer 23

Eclampsia
- headache , HTN (sys >=140 or diastolic >=90) is pree with sf now PLUS seizures hinted by post Irak state is eclampsia (CT shows bilateral frontal or occipital lobe edema

SF: headache, hyperreflexia, elevated Cr

Eclampsia seizures can cause brain injury or strokes

Question 24

27/40 ~
503
REVIEW
A 56-year-old man is brought to the emergency department by a friend after vomiting bright red blood several times during the past 2 hours. The patient has no abdominal pain or diarrhea. He has a history of peptic ulcer disease and alcoholic cirrhosis. His friend says that the patient continues to drink alcohol and is not sure whether he is taking his medications regularly. Temperature is 37.6 C (99.7 F), blood pressure is 96/62 mm Hg, and pulse is 112/min. The patient has muscle wasting and scleral icterus. The abdomen is nontender and distended with bulging flanks. Rectal examination shows interna hemorrhoids and maroon stool that is positive for occult blood. He is receiving a normal saline infusion through a peripheral intravenous catheter. Which of the following is the best next step in management of this patient?
O A. Administer octreotide infusion
O B. Obtain second intravenous access
O C. Perform esophagogastroduodenoscopy
O D. Perform mesenteric arteriography (
O E. Place Sengstaken-Blakemore tube

Answer 24

This patient has hematemesis in the setting of a history of peptic ulcer disease and alcoholic cirrhosis, which places I risk for rapid, life-threatening upper gastrointestinal bleeding (UGIB). Therefore, prompt and aggressive fluid rest should be the first step in management. All patients with acute hemorrhage should have vascular access establishe immediately with at least 2 large-bore intravenous lines.

Question 25

A 3-year-old boy is brought to the clinic due to decreased energy and yellow skin. The patient first became iI2 days ago when he developed a runny nose and cough. Yesterday, he had abdominal pain with nausea, but he has not had vomiting or diarrhea. The mother also noticed yellowing of the patient’s eyes and skin, and this morning he did not want to play or eat.
Medical history includes similar yellowing of the skin after birth that required phototherapy. Otherwise, he has been healthy.
Several members of his family had similar intermittent episodes of skin yellowing during childhood, and 2 relatives underwent splenectomies in adulthood. The patient takes no medications. Physical examination shows a tired-appearing toddler with
mild jaundice. Eye examination shows mild scleral icterus. The abdomen is soft and tender in the left upper quadrant. The spleen is 4 cm below the costal margin. The remainder of the examination shows no abnormalities. Laboratory results are as follows:

Hemoglobin 8.6 g/dL
Platelets
160,000/mm°
Leukocytes
7,000/mm°
Additional evaluation of this patient would most likely reveal which of the following laboratory findings? (Treatment)

Reticulocyte
Direct Coombs
Mean corpuscular hemoglobin concentration

Answer 25

Ret high
Direct coombs neg
MCHC high

HS
Folate , blood transfusion or splenectomy

Question 26

A 22-year-old woman, gravida 1 para 0, at 37 weeks gestation comes to labor and delivery for intermittent leakage of fluid for the past 6 hours. The patient has had some intermittent green-tinged fluid and is now having regular, painful contractions every 3-4 minutes. She has had no vaginal bleeding, and fetal movement is normal. The patient has had an uncomplicated pregnancy, and her group B Streptococcus culture was negative a week ago. She has no chronic medical conditions and has had no surgeries. Temperature is 37.2 C (99 F), blood pressure is 90/68 mm Hg, and pulse is 98/min. Fetal heart rate tracing is shown in the exhibit. Sterile speculum examination confirms rupture of membranes with meconium-stained amniotic fluid.
On digital cervical examination, the cervix is 6 cm dilated, 90% effaced, and the fetal vertex is at +1 station. The fetal heart rate pattern is unchanged (late decel) with maternal repositioning and oxygen administration. Which of the following is the best next step in management of this patient? Initial management
A. Amnioinfusion
O B. Biophysical profile
O C. Cesarean delivery
O D. Oxytocin augmentation
O E. Vacuum-assisted-vaginal-delivery

Answer 26

Csection
- FHR (late decel, no access

Initial management for late decel - oxygen, IVF, dc uteri tonics

Operative vaginal delivery if category 3 and complete dilation

Question 27

Management of different deceleration

Answer 27

Variable - recurrent do repositioning lateral or all fours first, amnioinfusion with saline if repositioning didn’t work
Late- oxygen, IVF, dc uteri tonics (oxytocin)

Question 28

Er Jul 18

A 33-year-old man comes to the physician reporting mild exertional shortness of breath and a “pounding heart over the lad months. He is uncomfortably aware of his heartbeat while lying on his left side. Vital signs include blood pressure of 150% mm Hg and pulse of 73/min. Which of the following is most likely responsible for his symploms?
O A. Aortic -regurgitation
O B. Aortie-stenosis
O C. Mitral stenosis
D. Pulmonic regurgitation
O E. Tricuspid-stenesis

Answer 28

AR
- regurgitation to lv causes increase LVEDV and myocardial huperteophy so LV size increases and gets closer to the chest wall causing a pounding sensation so aware of heart beat especially on left lateral decubitus

• wide pulse pressure inc sys dec diastolic
• RF: bicuspid aortic valve ,, RHd , and aortic root dilation (marfan and syphillis

Question 29

Management of actinic keratosis

Answer 29

Isolated : cryotherapy
Diffuse: topical fluorouraxil, imiquimod, tirbanibulin

Question 30

A 46-year-old man is brought to the emergency department after a motor vehicle collision. He is unresponsive, and his injuries include a basilar skull fracture, brain contusion, fractures of ribs 7-10, hemopneumothorax on the right, and a pelvic fracture. After multiple blood product transfusions, placement of a chest tube, and pelvic fixation, the patient’s condition stabilizes. On the fifth day of hospitalization, he is minimally responsive and has spontaneous respirations. Examination shows diminished bowel sounds and facial grimacing with palpation of the right upper quadrant of the abdomen. Rectal examination demonstrates no abnormalities. Nasogastric tube aspiration shows retention of gastric contents. Abdominal CT scan reveals gaseous distension of the small and large bowels without air-fluid levels. The Sallbladder is distended with no gallstones; there is a small amount of pericholecystic fluid. Which of the following is the most likely cause of this patient’s condition? Diagnostic,Tx
A. Acalculous cholecystitis
B. Duodenal-perforation
C. Mesenterie ischemia
D. Panereatitis
E. Small bowel obstruction

Answer 30

Alcalculous
- occura in critically ill patients, severe trauma, recent surgery, prolonged fasting, TPN leads to adúnalos ileus (distended bowels, diminished bowel sounds, retain gastric contents
- Diagnostic (Abdominal US preferred, HIDA OR CT—/pericholecystic fluid, distended gallbladder, wall thickening without stones
- treatment (antibiotics and percutaneous cholecystectomy once condition improves

Question 31

Causes of early , variable and late decels

Answer 31

Early - head compression or normal fetal tracing

Variable- cord compression, oligohydram, cord prolapse

“Late - placental insufficiency