Answer and Explanation 13

13.  The correct answer is B.  The sensitivity of CT scan for appendicitis is not 100%.  The standard of care is observation under general surgery in this age group.  The child does have some white blood cells in his urine but no bacteria.  This is not usual in appendicitis because of the close proximity of the ureter to the appendix.  When the appendix is inflamed it can cause dumping of WBC in the urine because of the inflammation caused to the ureter.  Children in this age group with constipation do not have voluntary guarding.  This patient does not need a testicular ultrasound because he has no evidence of torsion.

Question 13

13.  Your patient is a 7 year old male who presents with RLQ pain that has been present for the last 4 hours.  His abdominal exam exhibits voluntary guarding in the RLQ.  His testicle exam is normal.  His vitals are BP-112/68, P-114, RR-22, Temp 99.4.  His WBC 12.4, Hgb-12. 5, HCT-37.1.  His urine reveals 2-4 WBC, and no bacteria, no RBC.  His CT scan of his Abdomen and Pelvs was read per radiology as normal.  Given the above data, which of the following is the best management option?

A.  Discharge the patient home with a script for Bactrim and have the patient follow up with his doctor in 2 days

B.  Consult general surgery and admit the patient to the hospital for observation

C.  Order a testicular ultrasound

D.  Oder a fleets enema, it is not unusual for children in this age group to have voluntary guarding when they are constipated.

Answer and Explanation 12

12.  The correct answer is B.  This patient has a leaking abdominal aneurysm.  The aorta is aneurysmal and the patient has visible blood seen on his right side and around the aorta.  The patients gall bladder is not even visualized.  The patient has no evidence of air fluid levels or dilated loops of bowel seen on bowel obstructions.  The patient does not have a kidney mass.

Question 12

12.  Your patient is an 83 year old male who presents to the ER complaining of abdominal pain radiating through to his back.  You have obtained the following CT scan below.  Given this information, what is the best next management plan?

A.  Order an ultrasound of the the RUQ.  This patient is clearly has a gallbladder problem seen on this CT scan

B.  Consult vascular surgery, type and cross, and transfuse 4 units of blood, and have the nurse start a second large bore IV

C.  Consult nephrology for the right sided kidney mass

D.  Insert a nasogastric tube and admit to the hospital for a bowel obstruction

Answer and Explanation 11

11.  The correct answer is C.  Over treatment with proton pump inhibitors does not cause esophageal infections. Esophageal infections are largely diseases of immunosuppression, elderly, diabetic patients, or AIDS patients.  The most common organisms are CMV, Herpes, and fungal infections.  They are diagnosed by endoscopic evaluation.

Question 11

11.  Which of the following is incorrect regarding infections of the esophagus?

A.  Most common organism causing esophagitis include Candidia, CMV, and Herpes

B.  Infectious may occur in patients with AIDS or receiving immunosuppressive therapy

C.  They can be caused by over treatment with proton pump inhibitors

D. You may see infections in diabetic patients

Answer and Explanation 10

10.  The correct answer is D.  Patients with scleroderma frequently have esophageal motility disorders such as Achlasia.  These patients need aggressive treatment of their GERD with proton pump inhibitors.  The pathogenesis of achlasia involves loss of ganglion cells in Auerbach’s plexus leads to increased tone and impaired relaxation of the lower esophageal sphincter.  Treatment may involve dilation, treatment with nitroglycerin, treatment with calcium channel blockers, or treatment with anticholinergic agents that all help in relaxing the lower esophageal sphincter.

Question 10

10.  Which of the following is not true regarding Achlasia?

A.  Loss of ganglion cells in Auerbach’s plexus leads to increased tone and impaired relaxation of the lower esophageal sphincter.

B.  Achlasia usually responds to brisk dilatation of the lower esophageal sphincter with pneumatic bag

C.  Patients with diffuse esophageal spasm and its variants may respond to nitroglycerin or anticholinergic agents, or calcium channel blockers

D.  Patients with scleroderma are rarely afflicted with disorders like achlasia.