276.A 45-year-old woman presents to the ED with 1 day of painful rectal
bleeding. Review of systems is negative for weight loss, abdominal pain,
nausea, and vomiting. On physical examination, you note an exquisitely
tender swelling with engorgement and a bluish discoloration distal to the
anal verge. Her vital signs are HR 105 beats per minute, BP 140/70 mm Hg,
RR 18 breaths per minute, and temperature 99°F. Which of the following is
the next best step in management?
a. Recommend warm sitz baths, topical analgesics, stool softeners, a high-fiber
diet, and arrange for surgical follow-up.
b. Incision and drainage under local anesthesia or procedural sedation followed
by packing and surgical follow-up.
c. Obtain a complete blood cell (CBC) count, clotting studies, type and cross, and
arrange for emergent colonoscopy.
d. Excision under local anesthesia followed by sitz baths and analgesics.
e. Surgical consult for immediate operative management.
277.A 20-year-old man presents to the ED with fever and severe right lower
quadrant (RLQ) pain for 1 day. Prior to this episode, he reports 2 months of
crampy abdominal pain, generalized malaise, a 10-lb weight loss, and occasional
bloody diarrhea. On examination, his HR is 115 beats per minute, BP is
125/70 mm Hg, RR is 18 breaths per minute, and temperature is 100.8°F. His
only significant past medical history is recurrent perirectal abscesses. On
physical examination, the patient appears uncomfortable and has a tender
mass in the RLQ, without guarding or rebound. Rectal examination is posi-
tive for trace heme-positive stool. An abdominal computed tomography (CT)
scan reveals no peri-appendiceal fat stranding. There is inflammation of the
distal ileum and several areas of the colon. There are no rectal inflammatory
changes. Which of the following is the most likely diagnosis?
a. Crohn disease (CD)
b. Ulcerative colitis (UC)
c. Appendicitis
d. Pseudomembranous enterocolitis
e. Diverticulitis
298 Emergency Medicine