A 54-year-old male presents with a sudden onset of left lower quadrant pain, fever, and guarding. Vital signs reveal that the patient is hypotensive and tachycardic.  He appears septic.  Initial CBC results are as follows: WBC 15,000; Hgb 12.2; HCT 37%; Platelets 150,000.  WBC differential reveals a left shift. You suspect diverticulitis with a probable perforation.  Which of the following interventions would best confirm the diagnosis?

BONUS QUESTION: Pt. is a 54-year-old male with PMH significant for chronic alcohol abuse, who presents complaining of two-month history of intermittent, dull, aching, abdominal pain that radiates to the back, accompanied by weight loss, nausea, and frequent, foul-smelling ‘oily’ stools.  Which of the following conditions is revealed in the Abdominal x-ray?    

A 38-year-old male presents for initial history and physical at his new primary care provider office. He is currently asymptomatic but based on his sexual history, you decide to obtain screening hepatitis lab tests in addition to other screening tests. The following results are received from the laboratory: Hep A Ab negative HBcAb positive HBeAg negative HBsAg negative HBsAb positive Hep C Ab negative   Based on these results, which of the following interpretations is correct?

Mr. Jones, a 56-year-old male, presents with a chief complaint of abdominal pain, indigestion, weight loss, nausea and vomiting, and gray colored stools for the past month. His past medical history is positive for alcoholism. Lab results demonstrate an elevated serum amylase and lipase, decrease trypsinogen and positive fecal fat test.  Which of the following conditions is the most likely diagnosis?

A 68-year-old male with PMH significant for chronic alcohol abuse presents with a history of confabulation, confusion, and loss of memory. On examination he is found to have nystagmus, ataxia, and slight bilateral ophthalmoplegia. Which of the following vitamin deficiencies is the most likely cause of this patient’s symptoms?

An 85-year-old nursing home resident is brought to the emergency department due to 2 days of worsening abdominal pain and distension. He has had multiple episodes of vomiting and has not passed stool for 3 days. The patient has a history of Parkinson’s disease, hypertension, and chronic constipation. He has had no prior abdominal surgery.  Match the patient case with the correct Abdominal x-ray image below.

A 74-year-old male with PMH significant for coronary artery bypass surgery (6 years ago), history of alcohol abuse and remote history of cigarette use.  Patient reports that he quit smoking approximately 50 years ago.  Patient presents to your office, complaining of abdominal and ankle swelling, decreased energy, and poor appetite for the past 2 months. He says that he was previously in excellent health and walked 3 miles per day. Now he is too weak and tired to even care for his own yard. The patient is a fragile-appearing elderly man with temporal wasting. There is no jugular venous distention (JVD). The lungs are clear to auscultation. The heart sounds are regular, with no murmurs or gallops. The abdomen is protuberant with bulging flanks. Shifting dullness is present. There is 2+ ankle edema bilaterally and scattered telangiectasias on skin exam. He has no asterixis. Paracentesis is performed and ascites fluid analysis reveals serum-ascites albumin gradient (SAAG) = 1.4. Which of the following statements about this patient’s SAAG result is correct?

A 30-year-old female patient presents with a complaint of rectal pain that has been going on for about a week. She says she has lost 4 pounds (2 kg) over the past four weeks, has a low-grade fever, and has noticed a foul discharge in her undergarments. She also complains of vague abdominal pain and anorexia. The patient has no significant PMH.  She has no allergies. She has never had surgery before. A physical exam reveals a visibly distressed female with tenderness in the anal area. Examination is performed under anesthesia and reveals multiple fistulous tracts just above the dentate line. She has frank pus extruding in the anal canal. Which of the following statements about this condition is true?

A 45-year-old male is admitted to the medical floor of a hospital with complaints of increasing jaundice, swollen legs, and episodes of disorientation for the last several weeks. His abdomen is distended, and he looks ill. According to the family, the patient has a long history of alcohol abuse and has recently been diagnosed with cirrhosis of liver. On examination, he has a temperature of 99˚, BP 100/72 mm Hg, HR 86/minute. Sclerae are icteric, and he has 2+ pitting pedal edema. Lungs are clear, and heart sounds are normal. Abdomen is distended with moderate ascites, caput medusae, and no tenderness. Liver and spleen are not palpable. He is awake but drowsy and oriented to person and place but not to time. He does have a fine tremor in his hands. Labs show WBC 8,000 platelets 100,000, Hgb 12, AST 76 U/L, ALT 56 U/L, AP 62 U/L, and ammonia is 124 mg/dL.  At this time, which of the following interventions is most important, to avoid full decompensation into hepatic encephalopathy?

The accompanying image is showing the pterygopalatine ganglion at the tip of the probe.  Which cranial nerve provides preganglionic parasympathetic fibers that will synapse in this ganglion?