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The Quizzes about Gastrointestinal Bleeding (17 test)

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Gastrointestinal-Bleeding

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1. A 51-year-old man is brought to the emergency department (ED) by emergency medical services (EMS) with a blood pressure (BP) of 90/60 mm Hg, heart rate (HR) of 110 beats per minute, respiratory rate (RR) of 18 breaths per minute, and oxygen saturation of 97% on room The patient tells you that he has a history of bleeding ulcers. On examination, his abdomen is tender in the epigastric area. He is guaiac positive, with black stool. He has a bout of hematemesis and you notice that his BP is now 80/50 mm Hg, HR is 114 beats per minute, as he is slowly starting to drift off. Which of the following is the most appropriate next step in therapy?

  1. Assess airway, establish two large-bore intravenous (IV) lines, cross-match for two units of blood, administer 1 to 2 L of normal saline, and schedule an emer- gent endoscopy.
  2. Assess airway, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor.
  3. Place two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy.
  4. Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy.
  5. Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor.

2. A 45-year-old woman presents to the ED with 1 day of painful rectal bleeding. Review of systems is negative for weight loss, abdominal pain, nausea, and On physical examination, you note an exquisitely tender swelling with engorgement and a bluish discoloration distal to the anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg, RR 18 breaths per minute, and temperature 99°F. Which of the following is the next best step in management?

  1. Recommend warm sitz baths, topical analgesics, stool softeners, a high-fiber diet, and arrange for surgical follow-up.
  2. Incision and drainage under local anesthesia or procedural sedation followed by packing and surgical follow-up.
  3. Obtain a complete blood cell (CBC) count, clotting studies, type and cross, and arrange for emergent colonoscopy.
  4. Excision under local anesthesia followed by sitz baths and analgesics.
  5. Surgical consult for immediate operative  management.

3. A 20-year-old man presents to the ED with fever and severe right lower quadrant (RLQ) pain for 1 Prior to this episode, he reports 2 months of crampy abdominal pain, generalized malaise, a 10-lb weight loss, and occasional bloody diarrhea. On examination, his HR is 115 beats per minute, BP is 125/70 mm Hg, RR is 18 breaths per minute, and tem- perature is 100.8°F. His only significant past medical history is recurrent perirectal abscesses. On physical examination, the patient appears uncom- fortable and has a tender mass in the RLQ, without guarding or rebound. Rectal examination is positive for trace heme-positive stool. An abdominal computed tomographic (CT) scan reveals no periappendiceal fat stranding. There is inflammation of the distal ileum and several areas of the colon. There are no rectal inflammatory changes. Which of the following is the most likely diagnosis?

  1. Crohn disease (CD)
  2. Ulcerative colitis (UC)
  3. Appendicitis
  4. Pseudomembranous enterocolitis
  5. Diverticulitis

 

4. A 62-year-old man with a history of hypertension presents to the ED with severe constant mid-epigastric pain for the past Over the last sev- eral months, he has had intermittent pain shortly after eating, but never this severe. He states he now has generalized abdominal pain that began suddenly about 15 minutes ago. He has no history of trauma, has never had surgery, and takes no medications. His vitals include HR of 115 beats per minute lying supine, increasing to 135 when sitting up, BP of 170/105 mm Hg supine, falling to 145/85 mm Hg when sitting up. He appears pale. His abdomen is rigid and diffusely tender with guarding and rebound. Bowel sounds are absent and stool hemoccult is positive. The white blood cell (WBC) count is 8500/mL, hemoglobin 8.5 mg/dL, hematocrit 27%, and platelets 255/mL. Which of the following is the most likely diagnosis?

  1. Boerhaave syndrome
  2. Perforated gastric ulcer
  3. Abdominal aortic aneurysm (AAA)
  4. Inflammatory bowel disease (IBD)
  5. Diverticulosis

 

5. A 60-year-old man with a history of alcohol abuse presents to the ED with hematemesis for 1 He denies abdominal or chest pain. On physical examination, his eyes appear reddened which he attributes to hav- ing drunken heavily the night before (he also reveals vomiting several times after this recent binge). Vital signs are HR 115 beats per minute, BP 130/85 mm Hg, RR 18 breaths per minute, and temperature 99.5°F. Chest radio- graph is unremarkable. Laboratory results reveal a WBC 10,000/mL, hemo- globin 14 mg/dL, hematocrit 40%, and platelets 210/mL. Which diagnosis is endoscopic evaluation most likely to confirm?

  1. Esophageal varices
  2. Boerhaave syndrome
  3. Curling ulcer
  4. Perforated gastric ulcer
  5. Mallory-Weiss tear

 

6. A 50-year-old man is brought to the ED by ambulance with significant hematemesis. In the ambulance, paramedics placed two large-bore IVs and began infusing normal In the ED, his HR is 127 beats per minute, BP is 79/45 mm Hg, temperature is 97.9°F, RR is 24 breaths per minute, and oxygen saturation is 96%. On physical examination, his abdomen is nontender, but you note spider angiomata, palmar erythema, and gyneco- mastia. Laboratory results reveal WBC 9000/mL, hematocrit 28%, platelets 40/mL, aspartate transaminase (AST) 675 U/L, alanine transaminase (ALT) 325 U/L, alkaline phosphatase 95 U/L, total bilirubin 14.4 mg/dL, conju- gated bilirubin 12.9 mg/dL, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 26 mEq/L, blood urea nitrogen (BUN) 20 mg/dL, creatinine 1.1 mg/dL, and glucose 150 mg/dL. Which of the following is the most likely diagnosis?

  1. Perforated gastric ulcer
  2. Diverticulosis
  3. Splenic laceration
  4. Esophageal varices
  5. Ruptured AAA

 

7. A 55-year-old man is brought to the ED by his They state that he has been vomiting large amounts of bright red blood. The patient is an alcoholic with cirrhotic liver disease and a history of portal hypertension and esophageal varices. His vitals on arrival are HR 110 beats per minute, BP 80/55 mm Hg, RR 22 breaths per minute, and temperature 99°F. The patient appears pale and is in moderate distress. Which of the following is an inappropriate option in the initial management of a hypotensive patient with a history of known esophageal varices presenting with hematemesis?

  1. Sengstaken-Blakemore tube placement
  2. Two large-bore IV lines and volume repletion with crystalloid solutions
  3. Nasogastric (NG) lavage
  4. IV octreotide
  5. Gastrointestinal (GI) consult

 

8. A 70-year-old woman presents to the ED with dark stool for 3 She occasionally notes bright red blood mixed with the stool. Review of sys- tems is positive for decreased appetite, constipation, and a 10-lb weight loss over 2 months. She denies abdominal pain, nausea, vomiting, and fever, but feels increased weakness and fatigue. She also describes a raspy cough with white sputum production over the previous 2 weeks. Examination reveals she is pale, with a supine BP of 115/60 mm Hg and HR of 90 beats per minute. Standing BP is 100/50 mm Hg, with a pulse of 105 beats per minute. Which of the following is the most likely diagnosis?

  1. Hemorrhoids
  2. Diverticulitis
  3. Mallory-Weiss tear
  4. Diverticulosis
  5. Adenocarcinoma

 

9. A 76-year-old woman with a history of congestive heart failure, coro- nary artery disease, and an “irregular heart beat” is brought to the ED by her She has been complaining of increasing abdominal pain over the past several days. She denies nausea or vomiting and bowel movements remain unchanged. Vitals are HR of 114 beats per minute, BP 110/75 mm Hg, and temperature 98°F. On cardiac examination, her HR is irregularly irregular with no murmur detected. The abdomen is soft, nontender, and nondis- tended. The stool is heme-positive. This patient is at high risk for which of the following conditions?

  1. Perforated gastric ulcer
  2. Diverticulitis
  3. Acute cholecystitis
  4. Mesenteric ischemia
  5. Sigmoid volvulus

 

10. A 70-year-old woman with a history of hypertension, congestive heart failure, and atrial fibrillation presents to the ED with several hours of acute onset diffuse abdominal She denies any nausea or vomiting. The pain is constant, but she is unable to localize it. She was diagnosed with a renal artery thrombosis several years ago. Vital signs include HR of 95 beats per minute, BP of 110/70 mm Hg, and temperature of 98°F. Her abdomen is soft and mildly tender, despite her reported severe abdominal pain. Her WBC count is 12,000/mL, hematocrit 38%, platelets 250/mL, and lactate 8 mg/dL. The stool is traced heme-positive. You are concerned for acute mesenteric ischemia. What is the best way to diagnose this condition?

  1. Serum lactate levels
  2. Abdominal radiograph (supine and upright)
  3. CT scan
  4. Angiography
  5. Barium contrast study

 

11. A 55-year-old man with hypertension and end-stage renal disease requiring hemodialysis presents with 2 days of painless He reports similar episodes of bleeding in the past, which were attributed to angiodysplasia. He denies abdominal pain, nausea, vomiting, diarrhea, and fever. His vitals include HR of 90 beats per minute, BP of 145/95 mm Hg, RR of 18 breaths per minute, and temperature of 98°F. His abdomen is soft and nontender and his stool is grossly positive for blood. Which of the fol- lowing statements are true regarding angiodysplasia?

  1. They are responsible for over 50% of acute lower GI bleeding.
  2. They are more common in younger patients.
  3. Angiography is the most sensitive method for identifying angiodysplasias.
  4. They are less common in patients with end-stage renal disease.
  5. The majority of angiodysplasias are located on the right side of the colon.

 

12. A 49-year-old man is brought to the ED by EMS stating that he vomited approximately three cups of blood over the last 2 He also complains of epigastric pain. While examining the patient, he has another episode of hematemesis. You decide to place an NG tube. You insert the tube, confirm its placement, and attach it to suction. You retrieve 200 mL of coffee-ground blood. What is the most common etiology of an upper GI bleed?

  1. Varices
  2. Peptic ulcer
  3. Gastric erosions
  4. Mallory-Weiss tear
  5. Esophagitis

 

13. A 68-year-old man presents to the ED 4 hours after an upper endos- copy was performed for 5 months of progressive During the procedure, a 1-cm ulcerated lesion was found and biopsied. Now, the patient complains of severe neck and chest pain. His vitals are as follows: BP 135/80 mm Hg, HR 123 beats per minute, RR 26 breaths per minute, and temperature 101°F. On physical examination, he appears diaphoretic and in moderate distress with crepitus in the neck and a crunching sound over the heart. You obtain an electrocardiogram (ECG), which is notable for sinus tachycardia. After obtaining a surgical consult, which of the fol- lowing is the next best step in management?

  1. Perform an immediate bronchoscopy.
  2. Give aspirin 325 mg and obtain a cardiology consult for possible cardiac catheterization.
  3. Repeat the endoscopy to evaluate the biopsy site.
  4. Perform an immediate thoracotomy.
  5. Order an immediate esophagram with water-soluble agent.

 

14. A 65-year-old man with a history of occasional painless rectal bleed- ing presents with 2 to 3 days of constant, dull RLQ He also complains of fever, nausea, and decreased appetite. He had a colonoscopy 2 years ago that was significant for sigmoid and cecal diverticula but was otherwise normal. On physical examination he has RLQ tenderness with rebound and guarding. His vitals include HR of 95 beats per minute, BP of 130/85 mm Hg, and temperature of 101.3°F. The abdominal CT demonstrates the presence of sigmoid and cecal diverticula, inflammation of pericolic fat, thickening of the bowel wall, and a fluid-filled appendix. Which of the fol- lowing is the most appropriate next step in management?

  1. Discharge the patient with broad-spectrum oral antibiotics and surgical follow-up.
  2. Begin IV hydration and broad-spectrum antibiotics, keep the patient npo (noth- ing by mouth), and admit the patient to the hospital.
  3. Begin IV antibiotics and call a surgical consult for an emergent operative procedure.
  4. Arrange for an emergent barium enema to confirm the diagnosis.
  5. Begin sulfasalazine 3 to 4 g/d along with IV steroid therapy.

 

15. A 20-year-old man presents with several weeks of painful rectal He denies fever, nausea, or vomiting. He is sexually active with women only and usually uses condoms. He denies any history of CD, UC, or malignancy. He states that the pain is most severe during and immedi- ately after defecating. Bleeding is bright red and only enough to stain the toilet paper. Which of the following is the most common etiology of painful rectal bleeding?

  1. External hemorrhoid
  2. Anal fissure
  3. Anorectal tumor
  4. Internal hemorrhoid
  5. Venereal proctitis

 

16.  A 67-year-old woman with a history of hypertension and congestive heart failure presents with “burning” epigastric pain that began 2 hours after eating a She states that she has had similar pain over the past several weeks, and has been taking antacids and a medication that her primary care physician had prescribed with moderate relief. The pain has occurred with increasing frequency and now awakens her from sleep. She states she came to the ED today because the pain was not relieved with her usual medications. She denies nausea, vomiting, diarrhea, or fever. She also denies hematemesis, black stool, or bright red blood per rectum. On physical examination, she is tender at the epigastrium, with an otherwise normal abdominal, pulmonary, and heart examination. Stool guaiac tests positive for occult blood. Which of the following is the most common seri- ous complication of peptic ulcer disease?

  1. GI hemorrhage
  2. GI perforation
  3. GI penetration
  4. Gastric outlet obstruction
  5. Pernicious anemia

 

17. A 78-year-old man with a history of atherosclerotic heart disease and congestive heart failure presents with increasing abdominal The pain began suddenly a day ago and has progressively worsened since then. He denies nausea, vomiting, and diarrhea, but states that he had black tarry stool this morning. He denies any history of prior episodes of similar pain. Vitals are BP 120/65 mm Hg, HR 105 beats per minute, and temperature 99°F. The patient is at high risk for which of the following conditions?

  1. Cholecystitis
  2. Cecal volvulus
  3. Mesenteric ischemia
  4. Perforated peptic ulcer
  5. Small bowel obstruction

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