Gastrointestinal Pathology, Pathology, USMLE Step 1 - Full Vignette with Extended Explanations

A 20-year-old man presents with right lower quadrant abdominal pain that began centrally, fever, nausea, vomiting, and focal exam findings following recent travel. Laboratory studies show leukocytosis with neutrophilia and elevated CRP, while ultrasound reveals an abnormal tubular structure in the RLQ. What clinical and diagnostic features should guide your immediate management considerations in this acute abdominal scenario?

VIDEO INFO
Category: Gastrointestinal Pathology, Pathology, USMLE Step 1
Difficulty: Moderate - Intermediate level - Requires solid foundational knowledge
Question Type: Management - Clinical management decisions
Case Type: ED Case

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QUESTION
A 20-year-old man presents to the emergency department with 18 hours of right lower quadrant abdominal pain that began periumbilically, nausea with two episodes of non-bloody emesis, anorexia, and low-grade fever at home. He has no diarrhea, dysuria, or urinary frequency. Past medical history includes cervical spondylotic myelopathy with intermittent lower-limb spasticity. He returned recently from a 2-week trip to Costa Rica....

OPTIONS
A. Begin preoperative antibiotic prophylaxis and consult surgery for urgent laparoscopic appendectomy within the next several hours: administer cefazolin 2 g IV plus metronidazole 500 mg IV now as single pre-incision doses, keep the patient NPO, and continue IV isotonic fluids and analgesia.
B. Begin preoperative prophylaxis and consult surgery, but continue cefazolin 1 g IV every 8 hours until the operation in addition to a single pre-incision metronidazole dose, maintaining NPO status and IV fluids.
C. Defer antibiotics and obtain contrast-enhanced CT of the abdomen and pelvis with intravenous contrast for confirmation before initiating any antimicrobial therapy or contacting surgery.
D. Treat nonoperatively with broad-spectrum antibiotics and observation: start piperacillin-tazobactam 3.375 g IV every 6 hours for 24-48 hours, advance diet as tolerated, and arrange interval appendectomy only if symptoms persist.

CORRECT ANSWER
A. Begin preoperative antibiotic prophylaxis and consult surgery for urgent laparoscopic appendectomy within the next several hours: administer cefazolin 2 g IV plus metronidazole 500 mg IV now as single pre-incision doses, keep the patient NPO, and continue IV isotonic fluids and analgesia.

EXPLANATION
"Begin preoperative antibiotic prophylaxis and consult surgery for urgent laparoscopic appendectomy within the next several hours: administer cefazolin 2 g IV plus metronidazole 500 mg IV now as single pre-incision doses, keep the patient NPO, and continue IV isotonic fluids and analgesia." This is correct because the patient has classic uncomplicated acute appendicitis confirmed by point-of-care ultrasound (noncompressible blind-ended tube 8.2 mm with periappendiceal fat and appendicolith) and supportive labs. Early surgical consultation and urgent laparoscopic appendectomy is standard, and pre-incision antimicrobial prophylaxis should be a single dose active against skin flora and anaerobes (cefazolin 2 g IV plus metronidazole 500 mg IV)....


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