b.

Get angio
c. May need to resect bowel
20. Chronic mesenteric ischemia: LUQ pain with eating, weight loss, systemic hypotension
21. Hx of ulcerative colitis with severe abdominal pain with rebound, guarding and distention with massive
dilation of colon.
a. Dx? Toxic megacolon. NBSIM? Ex lap
b. Toxic megacolon also complication of C diff (abx use) + T cruzi (pt from developing country)
22. Female with severe lower abdominal pain, BL adnexal tenderness
a. Dx PID.
b. Tx broad spectrum abx to cover N gonorrhea, and Chlamydia. Tx ceftriaxone +
doxycycline/azithromycin
23. PID and now pt ℅ RUQ pain → fitz curtiz syndrome (hepatic capsule inflammation)
24. Appendicitis - usually go straight to surgery
a. But if NBME wants you to pick imaging do US for child or pregnant female or CT scan for
everyone else
25. Diabetic stable pt with abdominal pain and needs to get CT scan with contrast.
NBSIM: stop use of metformin because this causes lactic acidosis in chronic kidney dz or AKI pt
especially if pt has profound hypotension with prerenal AKI
26. Smoker with severe mid abdominal pain or back pain with profound hypotension. Pulsatile mass on
abdominal exam. Think AAA that’s ruptured
a. Calcifications anterior to vertebral body = ruptured or impending AAA
b. Get surgery NOW for AAA (can get abdominal US if NBME asking for imaging)
27. AAA Tx Options: Open Surgical Repair or EVAR
28. Complications of AAA repair:
a. Aorto-enteric fistula: Pt: Microcytic Anemia weeks-months after AAA repair, maybe formed
fistula between aorta and GI tract -> slowly leeching blood into GI tract. Colon cancer will be an
incorrect answer choice.
b. Anterior Spinal Artery syndrome: Paraplegic, cauda equina style symptoms, or urinary retention
after surgery due to Adam of Adamkiwetz (anterior 2/3 of spinal cord) ischemia. Pt: Multiple
episodes of profound hypotension during surgery
c. Acute Tubular Necrosis or Prerenal AKI: Rising Cr after AAA repair -> ischemia of kidneys during
surgery case
d. Endoleak: Pt: Person will have had AAA repair, Hg is slowly dropping, microcytic anemia
symptoms, on CT Angio: see contrast going beyond margins of excluded aneurysm
29. Biggest risk factor for AAA is smoking
30. Screen for AAA in:
a. male smokers b/w age 65-75
b. male smokers or nonsmokers above age 50 with first-degree relative who had AAA rupture
31. Screening: AAA > 5.5cm OR AAA >0.5 cm/6 months -> repair asap
a. Prior u/s (3-4 cm): repeat ultrasound screen in 2 years
b. Prior u/s (4-5 cm): repeat ultrasound screen in 1 year
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