A 72-year-old woman presents to her primary care physician's office with a 2-day history of escalating left lower quadrant abdominal pain, accompanied by chills and a persistent low-grade fever. She reports mild nausea and a recent decrease in bowel movements, but denies any frank rectal bleeding. Her medical history includes well-controlled hypertension and a prior episode of similar, though milder, abdominal discomfort about a year ago which resolved spontaneously. On examination, she appears uncomfortable. Her temperature is 38.5°C, blood pressure 148/88 mmHg, pulse 88/min, and respiratory rate 16/min. Abdominal palpation reveals localized tenderness with voluntary guarding in the left lower quadrant, but no rebound tenderness. Bowel sounds are diminished. A digital rectal exam reveals normal tone with brown stool, negative for occult blood. Initial laboratory workup is performed. Given the clinical presentation and initial findings, what is the most appropriate diagnostic imaging and subsequent immediate management strategy?

A 62-year-old woman with a history of chronic constipation presents to her primary care physician with a 5-day history of gradually worsening left lower quadrant abdominal pain, initially dull but now sharp and constant. She also reports chills, nausea, and a decreased appetite. Her current medications include a daily laxative. On examination, she appears acutely ill. Her temperature is 38.80C (101.80F), blood pressure 135/85 mmHg, pulse 110/min, and respirations 18/min. Abdominal palpation reveals significant tenderness, guarding, and rebound tenderness in the left lower quadrant. Bowel sounds are diminished. A digital rectal examination is unremarkable. Initial laboratory tests reveal a White Blood Cell count of 16.5 x 10^9/L (reference: 4.5-11.0 x 10^9/L) and a C-reactive protein of 125 mg/L (reference: <5 mg/L). Subsequent CT scan of the abdomen and pelvis with intravenous contrast reveals marked inflammation and wall thickening of the sigmoid colon with multiple diverticula, and a contained pericolic abscess measuring approximately 4.2 cm in diameter, without evidence of free air. Considering these findings, what is the most appropriate initial diagnostic and therapeutic approach for this patient?

A 68-year-old woman with a known history of diverticulosis and occasional constipation presents to the emergency department reporting three days of progressively worsening left lower quadrant abdominal pain, associated with chills and nausea. She reports a recent fever documented at home up to 39.20C. On examination, her vital signs are: heart rate 105 beats/min, temperature 39.00C, blood pressure 130/70 mmHg, and respiratory rate 18 breaths/min. Abdominal palpation reveals diffuse tenderness with localized guarding in the left lower quadrant, but no evidence of a rigid abdomen or widespread rebound tenderness. A recent computed tomography (CT) scan of her abdomen and pelvis, shown in a similar representation to Figure A, demonstrates a large perisigmoid fluid collection measuring approximately 6 cm x 5 cm, with surrounding inflammatory changes and small locules of air, though no overt free intraperitoneal air or extensive extravasation of contrast is observed. Her laboratory results include a white blood cell count of 18.5 x 10^9/L and a C-reactive protein of 120 mg/L. Considering her clinical presentation and imaging findings, what is the most likely diagnosis, and what is the most appropriate initial management strategy for this patient's condition?

A 65-year-old woman with a history of recurrent diverticulosis and chronic constipation presents to the emergency department complaining of severe left lower quadrant abdominal pain for the past 24 hours, accompanied by nausea and a subjective fever. She reports this pain is more intense than previous episodes. On examination, her temperature is 38.8°C (101.8°F), blood pressure 130/80 mmHg, heart rate 98 beats/min, and respiratory rate 18 breaths/min. Abdominal examination reveals significant tenderness with rebound and guarding in the left lower quadrant, and a palpable mass. Bowel sounds are diminished. Rectal examination is painful and reveals heme-positive stool. Given the patient's presentation and initial findings, what is the most appropriate initial management strategy, and what critical complication should be promptly ruled out?

A 68-year-old woman presents to the outpatient clinic for a follow-up appointment after an episode of uncomplicated acute diverticulitis three weeks ago. She was managed successfully as an outpatient with oral antibiotics for 10 days, prescribed based on a presumptive diagnosis and localized left lower quadrant tenderness. Her symptoms, which included mild abdominal pain and a low-grade fever, resolved completely within a few days. She reports a history of intermittent constipation, which she manages with dietary fiber. She has no prior history of colonoscopy. Physical examination reveals a soft, non-tender abdomen with normal bowel sounds. Laboratory results from today show a white blood cell count of 8.5 x 10^9/L and a C-reactive protein of 3 mg/L. Given her recent history and the importance of excluding other conditions, what is the most appropriate diagnostic assessment and a crucial lifestyle modification to recommend for long-term prevention?

A 55-year-old woman presents to her primary care physician with a 3-day history of gradually worsening left lower quadrant abdominal pain, accompanied by mild nausea and a subjective low-grade fever. She reports chronic constipation and mentions experiencing similar, though milder, episodes of abdominal discomfort over the past year that resolved on their own. She denies vomiting, diarrhea, or blood in her stool. Her vital signs in the clinic are: temperature 37.9°C, blood pressure 130/85 mmHg, pulse 92/min, respirations 16/min, and oxygen saturation 99% on room air. Physical examination reveals mild tenderness to palpation in the left lower quadrant without rebound or guarding. Bowel sounds are present and active. She is able to tolerate sips of water. Considering the clinical presentation and initial assessment, she is referred to the emergency department for further evaluation, where a CT scan of the abdomen and pelvis confirms inflammation and thickening of the sigmoid colon wall with surrounding fat stranding, but no evidence of abscess, perforation, or obstruction. Based on these findings, what is the most likely diagnosis for this patient, and what is the immediate appropriate management strategy?

A 55-year-old male presents to the Emergency Department with a four-day history of escalating left lower quadrant abdominal pain, accompanied by mild nausea and intermittent diarrhea. He reports a reduced appetite but has managed to tolerate small amounts of clear fluids. His vital signs on arrival are: Temperature 38.3°C, Heart Rate 88 bpm, Blood Pressure 132/90 mmHg, Respiratory Rate 16 breaths/min, and SaO2 99% on room air. Abdominal examination reveals localized tenderness to palpation in the left lower quadrant, without rebound or guarding, and normal bowel sounds. Laboratory results show a white blood cell count of 12.8 x 10^9/L with 82% neutrophils and a C-reactive protein of 78 mg/L. A computed tomography scan of the abdomen and pelvis with intravenous contrast was performed, revealing sigmoid colon wall thickening, localized fat stranding, and small diverticula, consistent with uncomplicated acute diverticulitis, with no evidence of abscess, perforation, or fistula. Based on these findings, what is the most appropriate initial management strategy, and what potential complication should be monitored for during outpatient care?

A 60-year-old male presents to the emergency department with acute onset, severe abdominal pain that began suddenly approximately 8 hours ago. He reports generalized abdominal tenderness, exacerbated by any movement, and has been nauseous with one episode of non-bloody vomiting. His past medical history is significant for poorly controlled type II diabetes mellitus, morbid obesity (BMI 38 kg/m2), asthma, depression, and a 20 pack-year smoking history. His current medications include insulin, metformin, albuterol, fluticasone, lithium, levothyroxine, and fluoxetine. On initial assessment, his temperature is 38.20C, blood pressure is 100/60 mmHg, pulse is 110/min, respirations are 22/min, and oxygen saturation is 95% on room air. Abdominal examination reveals diffuse tenderness with rebound and guarding, particularly prominent in the left lower quadrant. Bowel sounds are absent. An upright abdominal radiograph confirms the presence of free air under the diaphragm. Given this presentation and imaging, what is the most appropriate immediate therapeutic intervention, and what is the definitive surgical approach for the underlying condition?

A 68-year-old woman is referred from her primary care physician to the emergency department for acute onset abdominal pain. She reports the pain, localized to her left lower quadrant, began abruptly 18 hours ago and has steadily intensified, now accompanied by nausea and several episodes of non-bloody vomiting. Her past medical history includes type 2 diabetes mellitus, chronic hypertension, and hyperlipidemia. Current medications include lisinopril, metformin, and simvastatin. On examination, her temperature is 39.50C, blood pressure is 150/90 mmHg, pulse is 105/min, and respirations are 18/min. Abdominal assessment reveals marked tenderness and guarding in the left lower quadrant, with mild rebound tenderness. Cardiac and respiratory exams are unremarkable. Laboratory results are pending, but a preliminary report indicates a significant inflammatory response. Considering the patient's presentation and likely CT scan findings, what is the most appropriate initial management strategy, and what common complication should be vigilantly monitored for?

A 72-year-old woman presents to the urgent care clinic with 2 days of worsening left lower quadrant pain. She reports mild nausea but no vomiting, diarrhea, or urinary symptoms. Her past medical history includes type 2 diabetes managed with metformin and controlled hypertension. On examination, her temperature is 38.1 C (100.6 F), blood pressure 130/80 mm Hg, and heart rate 98/min. Abdominal examination reveals localized tenderness with mild guarding in the left lower quadrant, but no rebound tenderness or rigidity. Bowel sounds are diminished. Laboratory results are as follows: C-reactive protein (CRP): 45 mg/L (reference range: < 5 mg/L). Urinalysis is negative for leukocyte esterase and nitrites. What is the most probable diagnosis and the immediate next step in her management?

A 58-year-old woman presents to an outpatient clinic with a 2-day history of progressively worsening severe left-sided lower abdominal pain, accompanied by intermittent shaking chills and subjective fevers. She reports mild nausea but denies vomiting, diarrhea, or blood per rectum. Her medical history is significant for occasional constipation, but she takes no regular medications. On examination, her temperature is 38.8 C (101.8 F), blood pressure is 115/75 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination reveals marked tenderness in the left lower quadrant with voluntary guarding. Bowel sounds are diminished. There is no rebound tenderness or palpable mass. A rectal examination shows brown, guaiac-negative stool. Considering these findings, what is the most likely diagnosis and the appropriate initial management strategy?

A 65-year-old woman with a history of recurrent constipation is admitted to the hospital with acute onset severe left lower quadrant abdominal pain, fever, and nausea for the past 12 hours. Her vital signs are: Temperature 38.8°C, BP 130/80 mmHg, HR 98 bpm, RR 18 breaths/min. On physical examination, she exhibits marked tenderness and rigidity in the left lower quadrant. Her bowel sounds are diminished. Rectal examination reveals heme-positive stool. What is the most appropriate initial management strategy for this patient, and what potential complication should be monitored closely?

A 68-year-old woman presents to the general medicine clinic reporting persistent lower abdominal discomfort for the past two days, which has now intensified and shifted predominantly to the left lower quadrant. She describes the pain as dull and cramping initially, now sharp and constant, accompanied by a low-grade fever, nausea, and a decreased appetite. Her medical history includes well-controlled hypertension, dyslipidemia, and chronic constipation for which she occasionally uses over-the-counter stool softeners. She denies recent travel or antibiotic use. On examination, her temperature is 38.5°C, blood pressure is 138/88 mmHg, pulse 96/min, respirations 16/min, and oxygen saturation 97% on ambient air. Abdominal assessment reveals marked tenderness and guarding in the left lower quadrant, with mild rebound tenderness. Bowel sounds are diminished. Cardiopulmonary examination is unremarkable. Given her presentation, she is admitted for further evaluation and management. Considering her presentation and initial findings, what is the most appropriate initial management strategy and the most concerning potential acute complication requiring vigilance?

A 72-year-old woman with a chronic history of constipation and recurrent episodes of left lower quadrant pain, previously managed conservatively, presents to the emergency department. She reports that over the last 24 hours, her pain has become significantly more severe and constant, associated with chills, nausea, and inability to tolerate oral intake. She admits to a consistently low-fiber diet. On examination, her vital signs include a heart rate of 110 beats per minute, temperature of 39.2°C, blood pressure of 100/55 mmHg, and respiratory rate of 20 breaths per minute. Abdominal examination reveals distension, marked tenderness to palpation in the left lower quadrant with prominent rebound tenderness and rigid guarding. Bowel sounds are diminished. A computed tomography (CT) scan of the abdomen and pelvis was performed, revealing diffuse intra-abdominal free air and fluid, along with significant thickening and stranding around the sigmoid colon with clear evidence of a diverticular perforation. Given the clinical presentation and imaging findings, what is the most likely diagnosis and the immediate definitive management strategy?

A 68-year-old woman with a history of type 2 diabetes and chronic constipation is admitted to a general medical ward after experiencing a single episode of significant, painless bright red blood per rectum at home. She denies any abdominal pain, fever, or changes in bowel habits other than the bleeding. On admission, her vital signs are stable: temperature 37.1°C, blood pressure 138/86 mmHg, pulse 82/min, respiratory rate 14/min, and oxygen saturation 99% on room air. Physical examination reveals a mildly pale, non-distressed woman with a soft, non-tender abdomen and normoactive bowel sounds. Rectal examination confirms bright red blood, but no masses or hemorrhoids are palpated. The bleeding episode appears to have ceased spontaneously after arrival, with subsequent bowel movements appearing normal. Given this presentation, what is the most appropriate initial diagnostic approach and immediate therapeutic management?

A 68-year-old woman presents to her primary care physician's office reporting a sudden onset of large volume, bright red blood in her stool this morning. She describes the episode as painless, occurring during a routine bowel movement, without any associated abdominal discomfort, nausea, or vomiting. She denies changes in bowel habits leading up to this event. Her past medical history includes type 2 diabetes mellitus, essential hypertension, and chronic constipation for which she takes over-the-counter laxatives regularly. Her current medications include hydrochlorothiazide, metformin, and daily low-dose aspirin for cardiovascular prophylaxis. On examination, her temperature is 37.0 0B0C (98.6 0B0F), blood pressure is 118/72 mmHg, pulse is 78/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical examination reveals a soft, non-tender abdomen with normal bowel sounds, and no palpable masses or organomegaly. Rectal examination shows bright red blood without palpable masses or hemorrhoids. Given her presentation, which of the following is the most likely diagnosis and the immediate next step in management for this patient?