Referred pain from biliary colic typically presents in the patient’s:
Correct Answer B: Biliary colic (a symptom of cholelithiasis) is described as intermittent, intense, dull pain in the RUQ lasting a few hours. Its onset is typically within one hour of eating a meal. Referred pain to the right shoulder or back may also be experienced; this is termed: “Collins's sign”.
PEARL: Biliary colic is pain experienced in the RUQ with referred pain to the right shoulder/scapula.
A 43-year-old house painter presents with chronic pain of 6 weeks in the radial aspect of the wrist, radiating down the thumb. Her symptoms are worsened with pinching and with wrist movement. She has had to quit her job due to the severity of symptoms. On examination she has pain in the thumb with opening and closing her hand, and a Finkelstein’s test is positive.
The most effective treatment for this patient would be:
Correct Answer D: The history and physical findings are most consistent with de Quervain’s tenosynovitis, which affects the abductor pollicis longus and the extensor pollicis longus and brevis tendons. Local corticosteroid injection is the most effective treatment of persistent symptoms.
→ NSAIDs (choice B) may be helpful if symptoms are of recent onset and are not severe.
→ Although splinting (choice C) of the thumb and wrist helps, the loss of thumb range of motion for functional activities may lead to poor compliance with the splint.
→ Rest (choice A) alone has not been shown to be very helpful.
An 81-year-old male is scheduled to have an abdominal CT with contrast to assess for a possible tumor. His medical history is significant for COPD and type 2 diabetes mellitus. His serum creatinine level is 120 µmol/L.
Which one of the following would decrease the likelihood of contrast-related nephropathy in this patient?
Correct Answer D: Several interventions have been shown to reduce the risk of contrast-induced nephropathy (elevation of serum creatinine after contrast is administered). If there are no contraindications to volume expansion, isotonic intravenous fluids prior to and continued for several hours after contrast administration are recommended (choice D).
→ There are great heterogeneity and conflicting results in the available clinical trials and meta-analyses examining the effectiveness of acetylcysteine (choice A) in the prevention of contrast nephropathy. Given the conflicting data regarding benefit, there is no strong recommendation regarding the use of acetylcysteine. Although data regarding the efficacy of acetylcysteine are conflicting, if it is to be used, the preferred dose is 1200 mg administered orally twice daily on the day before and the day of the procedure to patients at risk for contrast nephropathy.
→ Several small trials have investigated the effect of diuretics (choice B). Mannitol was of no added benefit, while there was a suggestion that furosemide therapy slightly increased the risk.
→ Since alkalinization may protect against free radical injury, the possibility that sodium bicarbonate (choice C) may be superior to isotonic saline has been examined in a number of randomized trials and meta-analyses. The results were conflicting as some showed a significantly lower rate of contrast-induced nephropathy with sodium bicarbonate, while others found equivalent rates.
→ Volume depletion or nonsteroidal anti-inflammatory drugs (choice E), both of which can increase renal vasoconstriction, should be avoided.
A 56-year-old male had a 1-cm basal cell carcinoma resected from his temple area. The pathology report shows that cancer is present in one of the margins of the specimen.
Which one of the following would be the most appropriate next step?
Correct Answer E: Surgical re-excision is the preferred method of treatment for residual basal cell carcinomas, especially around the face. Imiquimod is not recommended for treating lesions on the head or face. Cryotherapy and curettage with electrodesiccation are recommended as primary treatments, but would not be appropriate in this case because lesions on the central part of the face are at risk for extensive subclinical spread.
A 65-year-old Caucasian man had undergone an emergent colectomy following a complete colonic obstruction by a sigmoid volvulus.
The patient has been on ticarcillin and sulbactam and NPO (nothing by mouth) for the past week. One week post-op, he developed bleeding from the venipuncture site and bleeding gums followed by an unexplained epistaxis. Vitals are stable and physical exam shows oozing of blood from the nose, gums and IV lines. You order some lab tests which show normal platelet count, but an abnormal PT (INR=3.9), a high normal aPTT (37 sec) and a normal bleeding time (3min).
Which of the following is the most likely diagnosis of this patient?
Correct Answer D: Vitamin K deficiency (choice D) is the most likely diagnosis of our patient. The body gets vitamin K from two sources: exogenous from the food and endogenous from the bacterial production of vitamin K in the colon. Our patient is taking broad spectrum antibiotics (loss of bacteria thus the endogenous source) and is NPO for a week (loss of the exogenous source). Coagulation profile usually shows prolongation of PT followed by prolonged PTT. PT is almost always more elevated than PTT.
→ Acquired VIII deficiency (choice A) would give a coagulation profile similar to hemophilia A i.e. normal PT, abnormal PTT, normal bleeding time and normal platelets count.
→ DIC (choice B) is common in the hospital setting and would present in a similar presentation to our patient; however all the coagulation will be disturbed (low platelet count, high PTT, high PT and high bleeding time).
→ Scurvy (Vit C def) (choice C) should be suspected in malnourished patients; a bleeding time is usually prolonged because of the vascular fragility.
→ Von Willebrand disease (choice E) will present in younger age groups with abnormal PTT and bleeding time.
Key point: Know how to diagnose Vit K deficiency On the exam you may not have the same scenario! Remember the warfarin overdose (Vit K antagonist) and the hemorrhagic disease of the newborn.
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