288.A 65-year-old man with a history of occasional painless rectal bleeding
presents with 2 to 3 days of constant, dull RLQ pain. He also complains of
fever, nausea, and decreased appetite. He had a colonoscopy 2 years ago that
was significant for sigmoid and cecal diverticula, but was otherwise normal.
On physical examination he has RLQ tenderness with rebound and guard-
ing. His vitals include HR of 95 beats per minute, BP of 130/85 mm Hg, and
temperature of 101.3°F. The abdominal CT demonstrates the presence of
sigmoid and cecal diverticula, inflammation of pericolic fat, thickening of the
bowel wall, and a fluid-filled appendix. Which of the following is the most
appropriate next step in management?
a. Discharge the patient with broad-spectrum oral antibiotics and surgical follow-up.
b. Begin IV hydration and broad-spectrum antibiotics, keep the patient npo (nothing
by mouth), and admit the patient to the hospital.
c. Begin IV antibiotics and call a surgical consult for an emergent operative procedure.
d. Arrange for an emergent barium enema to confirm the diagnosis.
e. Begin sulfasalazine 3 to 4 g/d along with IV steroid therapy.
289.A 20-year-old man presents with several weeks of painful rectal bleeding.
He denies fever, nausea, or vomiting. He is sexually active with women only
and usually uses condoms. He denies any history of CD, UC, or malignancy.
He states that the pain is most severe during and immediatelyafter defecating.
Bleeding is bright red and only enough to stain the toilet paper. Which of
the following is the most common etiology of painful rectal bleeding?
a. External hemorrhoid
b. Anal fissure
c. Anorectal tumor
d. Internal hemorrhoid
e. Venereal proctitis
304 Emergency Medicine