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

An 80-year-old male patient is recovering from a 3-vessel CABG he underwent 2 weeks prior when he develops abdominal pain with distension and obstipation. His heart rate is 115 bpm and his laboratory test results are notable for a WBC of 15 and potassium of 2.6. He is on a scheduled narcotic regimen prescribed by pain medicine for chronic back pain and ciprofloxacin for a UTI. He denies any history of melena and states his last screening colonoscopy was 4 months ago, which was normal. An obstructive series is ordered demonstrating the following findings:

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

A. Administer neostigmine with atropine available as needed
B. Obtain a CT of the abdomen/pelvis with a surgical consult
C. Start PO vancomycin and IV metronidazoleD.Place a nasogastric tube with serial abdominal examinations
D. Start a bowel regimen including enemas

Question 2# Print Question

A 60-year-old male with no significant past medical history presents with sigmoid diverticulitis diagnosed by CT scan, which demonstrated microperforation and phlegmon. His vitals on presentation are within normal limits, laboratory test results are only significant for a leukocytosis, and abdominal examination demonstrates mild left lower quadrant abdominal tenderness without rebound or guarding. He is admitted to the hospital, kept NPO, and started on IV ciprofloxacin and metronidazole. On hospital day 4 he is transferred to the ICU with atrial fibrillation with rapid ventricular rate but remains normotensive. He is started on metoprolol with successful rate control. Laboratory test results demonstrate an acute kidney injury. His abdomen is distended and tender diffusely to palpation.

What is the next BEST step in his management?

A. Change antibiotics to meropenem
B. Noncontrast CT abdomen/pelvis
C. Start anticoagulation
D. Exploratory laparotomy and colectomy
E. Amiodarone bolus and infusion

Question 3# Print Question

A 38-year-old male presents after a bout of hematemesis at home and subsequently vomits another 400 mL of bright red blood in the emergency room. He is tachycardic and hypotensive. Large bore IVs are obtained and he receives 2 units of packed red blood cells. He is intubated for airway protection and admitted to the ICU. On chart review he is found to have a significant alcohol abuse history and several admissions for alcoholic pancreatitis, but his liver function studies and coagulation parameters are within normal limits. A recent MRI of the abdomen and liver biopsy show no evidence of cirrhosis. The patient is started on an IV proton pump inhibitor and IV octreotide. Bedside ultrasound showed no signs of ascites. He subsequently undergoes an EGD that demonstrates oozing gastric varices that were sclerosed with cyanoacrylate, and EUS shows thrombosis of the splenic vein and calcification of the pancreas. He remains hemodynamically stable and is extubated after the procedure. Six hours later he has another large volume hematemesis and becomes hypotensive. He receives an additional 3 units or packed red blood cells and it stabilizes his blood pressure. 

What is the next BEST step?

A. Transjugular Intrahepatic Portosystemic Shunt (TIPS)
B. Nadolol
C. Continue massive transfusion protocol
D. Splenectomy
E. Catheter-directed tPA to splenic vein

Question 4# Print Question

A 70-year-old male with a history of diabetes, hypertension, and colon cancer status post a left hemicolectomy 10 years prior is brought to the emergency room from an outside hospital with a contained ruptured abdominal aortic aneurysm (AAA). On arrival he was hypotensive with a heart rate 115 bpm and blood pressure 85/55 mm Hg. He is taken emergently for endovascular aneurysm repair, which was uncomplicated. Postoperatively he is transferred to the surgical intensive care unit and remains stable overnight. Twelve hours later you are called to bedside as the patient is complaining of severe abdominal pain and distension. His vitals are as follows:

  • temperature 101.5°F
  • heart rate 110 bpm
  • blood pressure 100/70 mm Hg
  • urine output <15 mL/h over the last 4 hours

Laboratory test results are significant for:

  • a leukocytosis of 15,000 cell/mL
  • serum lactate of 3.1 mmol/L
  • creatinine is 2 mg/dL
  • The hemoglobin has remained stable from preoperative levels

Which is the MOST likely reason for the patients decline?

A. Endoleak with bleeding
B. Abdominal compartment syndrome
C. Hypovolemia with significant third spacing
D. Colonic ischemia
E. Retroperitoneal hematoma

Question 5# Print Question

A 55-year-old female is admitted to the surgical intensive care unit with severe abdominal pain, nausea, vomiting, and diarrhea for the last 3 days. Her vitals at arrival are as follows: heart rate 122 bpm, blood pressure 100/50 mm Hg, temperature 102°F. On examination her abdomen is diffusely tender with voluntary guarding. Laboratory test results are notable for a leukocytosis of 18,000 cells/mL and hypokalemia. A thorough medical history is significant for a recent diagnosis of ulcerative colitis treated with sulfasalazine and a recent urinary tract infection of which she completed a 7-day course of ciprofloxacin. A CT of the abdomen and pelvis is performed, which demonstrates a significantly dilated colon up to 6 cm in diameter and diffuse colonic wall thickening with patent vasculature.

What additional testing is required before full medical management can be initiated. 

A. CT angiography of the mesenteric vessels
B. Colonoscopy with biopsies
C. Clostridium difficile stool test
D. Serum CMV test
E. Barium enema

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