Today’s question will test your understanding of the most appropriate next steps in management based on a commonly tested GI condition.
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A 22-year-old male presents to the emergency department with severe abdominal pain that began 6 hours ago. The pain started around the umbilicus and migrated to the right lower quadrant. He also reports nausea, vomiting, and a decreased appetite. He denies any recent travel or sick contacts. His vital signs are as follows: temperature 38.5°C (101.3°F), blood pressure 125/80 mmHg, heart rate 105 beats/min, and respiratory rate 18 breaths/min. Physical examination reveals significant tenderness at McBurney's point, rebound tenderness and guarding. Laboratory results show a white blood cell count of 14,000/µL with 85% neutrophils. An abdominal ultrasound is inconclusive for appendicitis. The patient has not responded to pain management with IV morphine. Which of the following is the most appropriate next step in managing this patient?
A) Administer IV antibiotics and observe for improvement
B) Perform a CT scan of the abdomen and pelvis
C) Schedule an exploratory laparotomy
D) Schedule an upper endoscopy
E) Initiate a bowel regimen and reassess in 24 hours
F) Obtain a surgical consult for laparoscopic appendectomy
G) Perform a diagnostic peritoneal lavage
Detailed Breakdown of Answers + Correct Answer Below ⏬
ANSWER + QUESTION BREAKDOWN
The MENTAL MODEL used to answer this question comes from our detailed test-taking skills masterclass (check it out if you want to boost your USMLE test-taking skills). Here’s how to think through this question:
Step 1. Read the last line to determine the actual question: “Which of the following is the most appropriate next step in managing this patient?”
Step 2: Is this a first-, second-, or third-order question?
Answer: 2nd order. 1st: Diagnose the problem at hand, 2nd: Identify the next best step based on what’s been done thus far.
Step 3: Read the vignette carefully and ask yourself: “Based on my suspected diagnosis, what should I do next?”
Step 4. Look at the answer choices and select the option most closely resembling your final thought from “Step 3” above.
GENERAL ANALYSIS
In this scenario, the patient presents with symptoms and examination findings highly suggestive of acute appendicitis. The inconclusive ultrasound and the significant clinical suspicion necessitate further imaging to confirm the diagnosis.
ANSWER CHOICES:
CHOICE A: Administer IV antibiotics and observe for improvement
Explanation: While antibiotics may be part of treatment, observation without further diagnosis is inappropriate given the clinical suspicion. Further diagnostic confirmation is needed before deciding on treatment.
CHOICE B: Perform a CT scan of the abdomen and pelvis
Explanation: A CT scan provides detailed images and is highly effective in diagnosing appendicitis, especially when ultrasound results are inconclusive.
CHOICE C: Schedule an exploratory laparotomy
Explanation: This is a surgical procedure to explore the abdomen. It is more invasive and typically follows confirmed imaging findings.
CHOICE D: Schedule an upper endoscopy
Explanation: This would be more appropriate to examine the upper GI tract; it is not a relevant diagnostic test for suspected appendicitis.
CHOICE E: Initiate a bowel regimen and reassess in 24 hours
Explanation: This is appropriate for bowel preparation, not diagnosing or treating suspected appendicitis.
CHOICE F: Obtain a surgical consult for laparoscopic appendectomy
Explanation: Surgery is the definitive treatment for confirmed appendicitis. Imaging, however, is required before surgery.
CHOICE G: Perform a diagnostic peritoneal lavage
Explanation: This is used to detect internal bleeding, not to diagnose appendicitis.
FINAL VERDICT…
A CT scan is highly reliable for diagnosing appendicitis, providing detailed images that can confirm the presence of an inflamed appendix. Given the inconclusive ultrasound and strong clinical suspicion, a CT scan is the most appropriate next step to guide further management.
CORRECT ANSWER: B) Perform a CT scan of the abdomen and pelvis
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That’s it for question 76!
See ya next time 👋