Answer and Explanation 5

5.  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 5

5.  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 4

9.  The correct answer is C.  This patient likely has biliary dyskinesia.  This patient may have peptic ulcer disease but gall bladder disease has not been ruled out.  An abdominal series would not be helpful.  There is nothing in the data to suggest pneumoperitoneum or bowel obstruction.  A upper GI with small bowel follow through would be helpful only if a stricture was expected.  An ERCP would not be helpful because if the patient had a common bile duct stone, the patient would have some abnormalities on her liver function tests.

Question 4

4.  Your patient is a 43 year old female that presents with recurrent epigastric/RUQ pain that has been going on for several months.  She has had a negative gall bladder ultrasound.  Her labs including lipase and liver function tests were normal.  She has tried diet modifications and they have not helped.  Given the above data, what is the next best management option?

A.  Send the patient for an acute abdominal series

B.  Send the patient for an upper GI with small bowel follow through

C.  Send the patient for a HIDA scan

D.  Send the patient for an ERCP

Answer and Explanation 3

3.  D is the  correct answer.  This patient has pneumoperitoneum on the chest x ray.  This is a surgical emergency.  In general geriatric abdominal pain presenting the emergency department has a high mortality rate anyway, getting a general surgeon involved as soon as possible is the best management.  A CT scan is a long procedure and will take at least 90 minutes to prepare for.  Giving the patient pain and nausea medicine is a decent option but not the best option now.  Until it is clear exactly where the perforation is at, a NG tube should probably not be inserted yet.

Question 3

3.  Your patient is a 82 year old male who presented with a sudden onset of abdominal pain.  He is diffusely tender with involuntary guarding.  He has hypoactive bowel sounds.  He has had some nausea and vomiting.  His vital signs are as follows Temp 97.9,  O2 Sat 99% RR-20 Pulse 99, BP 143/76.  An upright chest x ray has been ordered prior to you seeing the patient by the triage nurse.  Take a look at the X Ray below.

Given the above data, what is the best management option for this patient now?

A.  Send the patient for a 3 dose oral and IV contrast CT scan of the Abdomen and pelvis

B.  Order the patient some Morphine 4 mg IV and Zofran 4 mg IV.

C.  Place an NG tube in the patient

D.  Call for a general surgery consult right now.

Answer and Explanation 2

2.  A is the correct answer.  CA 19-9 is a tumor marker for pancreatic cancer.  It is also used for gall bladder cancer, bile duct cancer and gastric cancer.  CA-125 is used in ovarian cancer.  Alpha Fetal Protein (AFP) is used in liver and germ cell cancers.  CA 15-3 is in breast cancer.

Question 2

2  Your patient is a 54 year old unfortunate male who presented to you with a 3 month history of Abdominal pain, nausea, vomiting, and an unintentional 34 pound weight loss.  You did a CT scan of his abdomen and pelvis with IV and oral contrast that the report reveals a mass at the head of the pancreas suspicious for adenocarcinoma of the pancreas.  Which tumor marker would it be appropriate to order at this point?

A.  CA 19-9

B.  CA-125

C.  CA 15-3

D.  Alpha Fetal Protein

Answer and Explanation 1

1.  The correct answer is B.  This patient has a clinical picture consistent with Zollinger Ellison Syndrome.  Somatostatin Receptor Scintigraphy is the single best imaging test for identifying this.  CLO testing is a biopsy test done during endoscopy to screen for H. Pylori and this would not be helpful because the patient is H. Pylori negative.  Prostaglandin levels have no correlation with the development of ulcers.  Cyclic AMP has nothing to do with the development of ulcers.  The only "cure" for Zollinger Ellison syndrome is if a gastrin secreting tumor can be found and be surgically removed.

Question 1

1.   Your patient is a 33 year old male who was underwent an extensive workup for epigastric abdominal pain.  He has an upper endoscopy that has revealed numerous ulcers in the stomach as well as in the duodenum.  He does not use alcohol nor does he use NSAIDS.  He has tested negative for H. Pylori.  He is currently on maximal therapy including Proton Pump inhibitors and Carafate.  What would be the natural next step in terms of workup for this patient.

A. Obtain a CLO test on the patient

B. Obtain somatostatin receptor scintigraphy

C.  Obtain Prostaglandin Levels

D.  Obtain Cyclic AMP Levels