2 MCQs for you

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pwanda

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Hi, just got 2 questions for you guys:


1 "A 78yr old woman with a PHx of atrial fibrillation, ischemic heart disease, cerebrovascular disease, peripheral vascular disease and peptic ulcer disease develops abdominal pain which gradually increases over 24hrs. On examination she looks unwell and has a temperature of 37.8C. She has mild generalised abdominal tenderness. No bowel sounds are audible. Investigations reveal an elevated neutrophil count and a low serum bicarbonate.

What is the most likely diagnosis?"

A. Diverticulitis
B. Mesenteric infarction
C. Perforated appendix
D. Perforated sigmoid carcinoma
E. Sigmoid volvulus

2 "An 81yr-old Greek woman who does not speak ENglish is brought to the Emergency Department by her son. He says that she has been complaining of severe pain in her right leg for the last 6 hrs. She has also become increasingly confused. His mother flew from Greece to Melbourne for a family visit seven days ago. SHe has temporal arteritis for which she normally takes prednisolone 4mg daily but she did not bring her tablets with her to Australia.

On examination she appears agitated and in pain. Her right leg is cold, pale and cyanosed. No pulses are palpabel below the femoral artery on the right. The femoral, popliteal and posterior tibial pulses are papable on the left but the dorsalis pedis pulse is not. A bruit is audible over the left femoral artery.

What is the most likely diagnosis?

A. An embolus to the right femoral artery
B. Extensive right deep vein thrombosis
C. Thrombosis of the right internal iliac artery
D. THrombosis of the right popliteal artery
E. Vasculitic occlusion of the right politeal artery
 
ThreadkillerMD said:
1. B

2. A


What's your reasoning in #1? My first guess would be appendicitis. It's really tough to say based on a bicarb level, though... 😕

How do you figure on #2? That has DVT written all over it based on the presentation but on physical exam, it presents as an clot being thrown to the peripheral circulation...
 
Pox in a box said:
What's your reasoning in #1? My first guess would be appendicitis. It's really tough to say based on a bicarb level, though... 😕

How do you figure on #2? That has DVT written all over it based on the presentation but on physical exam, it presents as an clot being thrown to the peripheral circulation...

I'm leaning more towards mesenteric ischemia for question #1 given the patient's age (I read in a review book, i think fa for step 2, think vascular problems such as AAA or mesenteric ischemia in elderly pts with abd pain), hx of Afib, and minimal tenderness on exam. A low bicarb/acidotic picture would also be c/w mesenteric ischemia. ...Although I don't know of a good way to r/o appendicitis for this question.
 
ljl1982 said:
I'm leaning more towards mesenteric ischemia for question #1 given the patient's age (I read in a review book, i think fa for step 2, think vascular problems such as AAA or mesenteric ischemia in elderly pts with abd pain), hx of Afib, and minimal tenderness on exam. A low bicarb/acidotic picture would also be c/w mesenteric ischemia. ...Although I don't know of a good way to r/o appendicitis for this question.

I don't have a good way to r/o appendicitis or mesenteric ischemia at this point. Was this question in a review book or simply made up? Seems like we need more details.
 
Pox in a box said:
I don't have a good way to r/o appendicitis or mesenteric ischemia at this point. Was this question in a review book or simply made up? Seems like we need more details.

i agree. the only question i have is do you get a change in bicarb with appendicitis?
 
Well, I thought "classically" with mesenteric ischemia you have a lactic acidosis, which would give you an AG metabolic acidosis. I feel like that's what this question is getting at with the low bicarb, even though they don't outright tell you there is an AG (and we don't know a pH). Given the rest of the patient's vasculopathic hx, elderly age, "pain out of proportion to exam," and the afib as a possible embolic source, I would be most concerned about the mesenteric ischemia, and think that's probably the answer to the question.

Can you say for sure no appendicits? I guess not. I don't ever remember hearing about low bicarb/acidosis with appendicitis as an initial presentation.
 
4424 said:
i agree. the only question i have is do you get a change in bicarb with appendicitis?

No...I don't know an association with electrolytes and the presentation of appendicitis. Without seeing the choices, I just thought about that as a diagnosis in an elderly person with lower quadrant pain. I thought about ischemic bowel second...I think we're all on the right track. Would the author please explain what he/she is thinking?
 
Pox in a box said:
What's your reasoning in #1? My first guess would be appendicitis. It's really tough to say based on a bicarb level, though... 😕

How do you figure on #2? That has DVT written all over it based on the presentation but on physical exam, it presents as an clot being thrown to the peripheral circulation...

Q2 - the pt has classical symptoms of arterial occlusion. The long flight was a red-herring.
 
pwanda said:
Q2 - the pt has classical symptoms of arterial occlusion. The long flight was a red-herring.

Right, but you still can't rule out a DVT without ultrasonography, which you better do to CYA.
 
pwanda said:
Q2 - the pt has classical symptoms of arterial occlusion. The long flight was a red-herring.

exactly. to me this has peripheral vascular disease written all over it...specifically an acute occlusion. remember all the p's for an arterial occlusion...pain, pallor, polar, pulseless, paresthesia, paralysis. also note that there is a lack of swelling which would point more towards DVT. the pressure from DVT would have to be pretty high to cut off the arterial circulation.

what about the vasculitis she has too? i don't know if there's an association...anybody?

for #1 it's missing the traditional "pain out of proportion to PE findings" line you always here about for mesenteric infarction...however that lady is a vasculopath and i'd still got w/ it given all those risk factors...perhaps she's diabetic as well and her visceral innervation is shot? next i'd look at a sigmoid volvulus...i'm picturing that elderly "institutionalized or nursing home" patient like they always talk about. w/ the limited hx and physical findings (specifically no peritoneal signs) i'd stray away from a perforation.

let us know the answer.
 
Ok, well answers:

Q1 = B

Q2 = A

Think they were reasonably straightforward, given the relevancy of the phx.
 
pwanda said:
Ok, well answers:

Q1 = B

Q2 = A

Think they were reasonably straightforward, given the relevancy of the phx.

What's the mechanism of the bicarb?
 
Pox in a box said:
What's the mechanism of the bicarb?

probably a lactic acidosis from the ischemia/hypopefusion. you could get a lactate to confirm it if you really wanted.
 
lattimer13 said:
probably a lactic acidosis from the ischemia/hypopefusion. you could get a lactate to confirm it if you really wanted.

👍 I concur
 
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