Practice BCQs

A 65-year-old male presents with acutely worsening pain and nausea. He has been experiencing left lower quadrant abdominal pain for two weeks. He has no past medical history, but his body mass index (BMI) is 29 kg/m2. On examination, he has signs of rebound and guarding. His bowel sounds are absent. What is the most appropriate next step in the management of this patient?

• Abdominal ultrasound

• Abdominopelvic CT

• Colonoscopy

• Exploratory surgery

Answer explanation

The patient presents with clinical concern for diverticulitis and possible complication of peritonitis. Performing a CT examination can allow preoperative assessment of the severity of the disease, the presence of complicating abscesses, the exact location of the disease, and other findings that might influence surgical approach and management.

Not all cases of diverticulitis, including those with peritoneal signs, require an operation. CT is an excellent triage mechanism to differentiate between those that do and do not require surgery.

A 17-year-old male patient was evaluated in the emergency department for abdominal pain. He states he had an acute onset of abdominal pain and nausea without vomiting while he was studying 10 hours ago. His last defecation was 12 hours ago, without any significant change in the consistency. He denied any urinary symptoms. His vital signs were blood pressure of 114/80 mmHg, heart rate of 108 beats per minute, respiratory rate of 22 beats per minute, and temperature of 37.8 C (100 F). His abdominal physical examination was remarkable for localized abdominal tenderness at the right lower quadrant accompanied by a positive Rovsing sign. His laboratory tests were a white blood cell count of 11800 cells/mm³ (polymorphonuclear 84%), hemoglobin of 13.4 mg/dl, and platelet count of 123000 cells/uL. What is the subsequent preferred management?

• Obtaining abdominal magnetic resonance imaging (MRI) without intravenous contrast

• Obtaining abdominal duplex ultrasonography within the next 6 hours

• Laparoscopic appendectomy

• Request blood urea nitrogen and creatinine

Answer explanation

If a similar history and physical examination were discussed in a female patient, obtaining abdominal ultrasonography might be prioritized to exclude the possibility of a gynecology issue, including an acute ovarian torsion. The combination of the clinical presentation, history of pain, nausea, and laboratory tests is suggestive of acute abdominal pain due to acute appendicitis and surgery is indicated.

A 38-year-old man develops severe itching and hives all over his body within a few minutes after starting to eat at a restaurant and paramedics are called. His heart rate is 102 bpm, and his blood pressure is 85/65 mmHg. Which of the following signs or symptoms warrants urgent epinephrine administration?

• Reduced blood pressure

• Involvement of the skin mucosal surfaces

• Severe itching with wheals on the body

• Stomach pain, vomiting, and diarrhea

Answer explanation

This is a case of an anaphylactic reaction, and epinephrine is administered in anaphylaxis if the patient cannot maintain blood pressure, has difficulty breathing, or has end-organ damage.

A 43-year-old man reports home systolic blood pressures of 140-145 mmHg and diastolic blood pressures of 75-80 mmHg. He is asymptomatic, walks 45 minutes daily, and does not take any medications. In the clinic, the average of two blood pressure readings is 122/78 mmHg, and the rest of the examination is unremarkable. What is the most appropriate management?

• Reassurance and follow-up in three months

• Reassurance and follow-up in six months

• Ambulatory blood pressure monitoring

• 24-hour urinary vanillylmandelic acid (VMA) measurement

Answer explanation

This patient has elevated blood pressure at home but normal readings in the clinic; therefore, ambulatory blood pressure monitoring is required to exclude masked hypertension.

Ambulatory blood pressure monitoring is the most accurate method to diagnose hypertension.

A 35-year-old man presents to the clinic for a routine annual visit. He feels well and reports no abnormalities. His medical history is unremarkable, and he takes no medications regularly. He is very particular about his diet and exercises regularly. He smokes one pack of cigarettes per day and a 12-pack of beer every week. Family history is remarkable for essential hypertension in both parents. His body mass index is 24 kg/m2. Physical examination is normal except for a xanthelasma present on the right upper eyelid. A lipid panel is ordered, which shows a cholesterol level of 170 mg/dL, triglyceride (TG) level of 500 mg/dl, low-density lipoproteins (LDL) level of 90 mg/dl, high-density lipoproteins (HDL) level of 50 mg/dl. In addition to the lifestyle modifications, which of the following is the most appropriate recommendation for the management of this patient?

• Gemfibrozil

• Ezetimibe

• Niacin

• Lovastatin

Answer explanation

The patient has presented with hypertriglyceridemia, as evident by the presence of xanthelasma and the lipid panel showing high TG (above 200 mg/dl) and normal HDL (above 50 mg/dl) and LDL levels (below 100 mg/dl). The management is aimed at initiating lifestyle changes, such as cessation of tobacco use/ alcohol intake, weight loss, exercise, and optimizing glycemic control, as well as screening for possible etiologies.

Fibrates can markedly lower triglyceride levels (40 to 60 percent) and modestly raise HDL-C levels (15 to 25 percent). Other FDA approved fibrates are fenofibrate and bezafibrate.

A 73-year-old male presents to the emergency department with chest pain. The pain occurs only with exertion and is relieved with nitroglycerin. He has a past medical history of hyperlipidemia and peripheral arterial disease. He smokes 1 pack of cigarettes per day and has a 30 pack-year smoking history. The initial evaluation is unremarkable with normal vital signs and no significant findings on examination. His electrocardiogram is significant only for left axis deviation. Which of the following medications has been shown to improve mortality in patients with this disease?

• Beta-blockers

• Diuretics

• Heparin

• Calcium channel blockers

Answer explanation

The patient in the clinical scenario most likely presents with angina due to coronary artery disease (CAD) with typical symptoms and multiple risk factors for CAD. Beta-blockers reduce heart rate and indirectly improve coronary circulation and have been shown to improve mortality in patients with CAD.

Beta-blockers cause a decrease in heart rate, contractility, and blood pressure, thereby reducing myocardial oxygen demand in patients with CAD.

A 60-year-old patient with no risk factors for cardiac disease with typical angina symptoms presents to the emergency. His vitals and physical examination are normal. ECG and cardiac enzymes are also normal. What is the next best step in management?

• Exercise ECG testing

• Cardiac catheterization

• Exercise echocardiography

• Myocardial perfusion imaging

Answer explanation

Exercise ECG testing is inexpensive and simple.

Exercise ECG is not helpful in the case of an abnormal resting ECG.

Chemical stress testing and imaging are used for patients with abnormal ECGs and those unable to exercise.

Patients who have an abnormal resting ECG will likely go to the cath lab.

What is the first test that should be performed when a patient presents with signs and symptoms of an acute stroke?

• Complete blood count

• Brain computed tomography (CT)

• Electrocardiogram (ECG)

• Brain magnetic resonance imaging (MRI)

Answer explanation

A brain CT scan is ordered as soon as possible to rule out the presence of hemorrhage, hematoma, or other pathology, which may make thrombolytic therapy dangerous.

If the patient is a candidate for thrombolysis, a noncontrast CT is done to assess for intracranial hemorrhage.

A 17-year-old female presents to the office after three months of alternating bowel habits. She states that she has had loose stools that alternate with constipation. She feels that her symptoms get exaggerated when she is under stress. A review of systems is positive for abdominal pain linked to her bowel movements. She denies vomiting, nausea, anorexia, weight loss, or bloody stools. Her past medical history is significant for hypothyroidism managed with levothyroxine. Her menstrual cycle is irregular, with a cycle varying between 24 and 35 days. Examination shows a soft, non-tender abdomen with no organomegaly. What antibiotic may be beneficial for her?

• Trimethoprim/sulfamethoxazole

• Metronidazole

• Ciprofloxacin

• Rifaximin

  Submit

Answer explanation

This patient presents with the classic symptoms of irritable bowel syndrome (IBS).

Rifaximin is a nonabsorbable broad-spectrum antibiotic sometimes used to treat patients with irritable bowel syndrome.

Patients with irritable bowel syndrome who take rifaximin have less abdominal pain and diarrhea. The effectiveness of rifaximin in patients with IBS is used as evidence to support the idea that bacterial overgrowth plays a role in the etiology of IBS.

Despite rifaximin showing promise in the treatment of IBS, the mainstay of treatment is still based on diet, reassurance, and counseling.

A 31-year-old female presents with progressive abdominal discomfort for the past few weeks. Most days she has diarrhea, but on occasion, she has constipation. She also reports bloating and flatulence. Stress and eating seem to increase symptoms, while defecation improves her condition. She has not traveled out of the United States. Temperature is 36.7 C (98 F), blood pressure is 118/74 mm Hg, the pulse is 74/min, and respirations are 14/min. A physical exam is essentially normal. Labs show white blood cell count 7000 cells/microliter, hemoglobin 10 grams/dL, hematocrit 30%, platelets 200,000, AST 91 U/L, ALT 112 U/L, and erythrocyte sedimentation rate of 49 mm/hr. Stool shows no blood but is positive for lactoferrin. Which of the following is the next best step in the management of this patient?

• Fiber supplements

• Colonoscopy

• Biofeedback and antidepressants

• Broad-spectrum antibiotics

Answer explanation

The patient has some alarm features including anemia, erythrocyte sedimentation rate elevation, and the stool is positive for lactoferrin.

Inflammatory bowel disease, microscopic gastrointestinal bleed, and malignancy must be ruled out.

Colonoscopy aids in visualization of the entire colon, facilitates removal of polyps and tissue biopsies, and sometimes can facilitate direct cauterization of bleeding vessels.