Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders--->Small Intestine
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Question 1# Print Question

A 50-year-old man with a history of hypertension, active smoking, and a laparoscopic Roux-en-Y gastric bypass 5 years prior presents to the emergency department with 4 weeks of upper abdominal pain that acutely worsened on the morning of presentation. He:

  • is toxic appearing
  • temperature 100°F
  • heart rate 120/min
  • blood pressure 90/50 mm Hg
  • respiratory rate 25/min
  • oxygen saturation 98% on room air

His abdomen is diffusely tender and he is guarding. He has:

  • WBC 20,000/mm3
  • Hgb 12 mg/dL
  • actate 4 mg/dL

Blood cultures are sent and broad-spectrum antibiotics administered. A CT scan shows a moderate amount of free fluid in the upper abdomen.

What is the BEST definitive management of this patient?

A. Admission to the intensive care unit for serial abdominal examinations and intravenous antibiotics
B. Nasogastric tube placement
C. Consult to gastroenterology for urgent endoscopy
D. Urgent operation
E. Consult to interventional radiology for angioembolization

Question 2# Print Question

A 66-year-old man presents to the emergency department with melanotic stools, dizziness, and hypotension. He is admitted to the ICU, his hemoglobin and blood pressure normalize after three units of packed red blood cells, and his melena slows down. Upper GI endoscopy and colonoscopy are performed, which do not show any source of bleeding. Shortly thereafter he develops more melena and a drop in hemoglobin. A repeat endoscopy, tagged RBC study, and CT angiogram all fail to identify a bleeding source, but hemoglobin again normalizes with two more units of packed red blood cells. The following day he again develops hematochezia, with a worsening transfusion requirement and associated hypotension.

Which of the following is the next best step to managing this bleeding?

A. Continued transfusion, hold subcutaneous heparin, observe
B. Repeat tagged RBC study
C. Mesenteric angiogram
D. Urgent exploratory laparotomy
E. Video capsule endoscopy (VCE)

Question 3# Print Question

A 75-year-old woman presents to the emergency department with perforated diverticulitis and undergoes emergent surgery in which there is diffused fecal contamination. She is admitted to the ICU postoperatively, where she remains on broad-spectrum antibiotics and is hemodynamically stable. She is started on clear liquids on postoperative day 2. On postoperative day 4 her abdomen is distended, and she is vomiting and has no ostomy output. An abdominal X-ray shows diffusely dilated loops of small bowel.

What is the best next step in management of this patient?

A. Nasogastric tube placement
B. Urgent surgical re-exploration
C. Mineral oil enema
D. Initiate pro-motility agents and antiemetics
E. GI consult for EGD

Question 4# Print Question

A 34-year-old man with a history of Crohn disease presents with foul-smelling drainage from his abdominal wall. He has experienced malaise and poor oral intake over the preceding 3 weeks and had been having worsening abdominal pain for 5 days. In the last 3 days, he noticed swelling of his abdominal wall superior to his umbilicus, in an area that began to drain foul-smelling, greenish drainage. The area has become erythematous and very tender. The drainage has increased in volume over the past 24 hours to the point that it saturates his clothes, and he has started to develop fevers, chills, and dark urine. On arrival he has the following vitals:

  • temperature 102°F
  • heart rate 110 beats/min
  • blood pressure 95/50 mm Hg
  • respiratory rate 18/min
  • oxygen saturation 98% on room air

A CT scan shows oral contrast extravasation from the small bowel that exits at the site of drainage, but no drainable fluid collection in the abdominal wall.

Which is the most appropriate management at this time? 

A. Take the patient to the OR urgently for exploratory laparotomy
B. Start broad spectrum antibiotics, monitor fluid and electrolyte status closely, nutritional support
C. Perform incision and drainage at the bedside
D. Percutaneous jejunostomy tube placement, initiate tube feeding
E. Consult gastroenterology for endoscopy

Category: Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders--->Small Intestine
Page: 1 of 1