Master the board step 3

Master the Boards: USMLE Step 3
Acute Appendicitis
Acute appendicitis presents as follows:
Rovsing’s sign: palpation of
LLQ increases the pain felt
in RLQ
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It classically begins with anorexia
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This is followed by vague periumbilical pain, which several hours later
becomes sharp, severe, constant, and localized to the right lower quadrant
of the abdomen.
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Tenderness, guarding, and rebound are found to the right and below the
umbilicus (but not elsewhere in the belly).
Diagnostic Testing
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Look for fever and leukocytosis in the 10,000–15,000 range, with neutrophilia
and immature forms.
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If diagnosis is unclear by clinical history and exam, the best imaging study
is CT scan; less optimal is ultrasound of the abdomen.
Treatment
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Administer IV antibiotics before appendectomy:
--
Cipro and metronidazole
--
Ampicillin/sulbactam
--
Levofloxacin and clindamycin
--
Cefoxitin or cefotetan
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If appendix is perforated, continue IV until fever and WBC count have
normalized.
Chronic Ulcerative Colitis (CUC)
CUC is managed medically. Elective surgery is the answer under the following
conditions:
··
Disease has been present more than 20 years (high incidence of malignant
degeneration).
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There have been multiple hospitalizations.
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The patient needs chronic high-dose steroids or immunosuppressant.
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There is toxic megacolon (abdominal pain, fever, leukocytosis, epigastric
tenderness, massively distended transverse colon on x-rays with gas within
the wall of the colon).
Basic Science Correlate
Ulcerative colitis extends from the anal verge in an uninterrupted pattern to
the entire colon.
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