ABIM Exam Review Practice Question of the Week: 67-year-old to the Emergency Room with left lower quadrant pain
Below is an Internal Medicine Board Review and ABIM exam practice question directly from Knowmedge’s QVault.
67-year-old male presents to the emergency room with left lower quadrant pain that he has been experiencing for five days. He says the pain is constant and sharp in nature. Currently he says the pain is 6 on a scale of 1 to 10. There are no identifiable alleviating or aggravating factors. He denies nausea and vomiting and has not noticed any blood in his stools. He did take his temperature at home and has had a fever as high as 101°F. The patient has never had these symptoms before. On physical examination, there is tenderness in the left lower quadrant. Bowel sounds are present. There is no guarding or rebound tenderness appreciated. A rectal exam is performed and is negative for blood. He undergoes complete blood count (CBC) and basic metabolic panel (BMP) blood tests that reveal elevated white blood cell count. Based on what this patient likely has, which of the following is the most appropriate diagnostic test and management for this patient?
A. Perform a colonoscopy and initiate ciprofloxacin and metronidazole
B. Check lactic acid blood level and refer patient to a surgeon
C. Check CT scan of the abdomen with IV contrast and refer patient to a surgeon
D. Check CT scan of the abdomen and initiate ciprofloxacin and metronidazole
E. Perform a colonoscopy and refer patient to a surgeon
Explanation
From the patient’s presentation, he is likely suffering from an initial bout of diverticulitis. Diverticulitis results from obstruction at the diverticulum by fecal matter that leads to bacterial overgrowth. Because diverticulitis usually occurs in the sigmoid colon, the most common presenting symptom is left lower quadrant pain. Other common presenting signs include fever and leukocytosis. The best diagnostic modality to order when diverticulitis is suspected is CT scan of the abdomen with IV contrast.
In an acute setting of diverticulitis, colonoscopy should not be performed because air inflation can increase the risk of perforation. A colonoscopy should be performed four to six weeks after the bout of diverticulitis first occurs. With an initial bout of diverticulitis, antibiotics should be given to cover gram negative bacilli and anaerobes. This can best be achieved by treating the patient with a fluoroquinolone and metronidazole. Since this is the patient’s first bout of diverticulitis, Choice D (Check CT scan of the abdomen and start antibiotics with ciprofloxacin and metronidazole) would be preferred over Choice C (Check CT scan of the abdomen with IV contrast and refer patient to a surgeon). If the patient, however, has recurrent bouts of diverticulitis, then a referral to a surgeon should be made.
Other reasons to refer the patient to a surgeon would be if the CT abdomen reveals obstruction, abscess formation, fistula formation or perforation.
You can see all the previous ABIM Exam Review Questions of the Week at the Knowmedge Blog. You can find also additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault.
