Internal Medicine Quiz

Prepared by Richard W. Carlson, MD, PhD, Chair, Department of Medicine, Maricopa Integrated Health System,

Phoenix, Ariz; Professor of Medicine, Mayo Medical School, Scottsdale, Ariz; Professor of Clinical Medicine,

University of Arizona, Tucson, Ariz; Silke Rempe, MD, Resident; Renaud Gueret, MD, Resident; Derrick

Aipoalani, DO, Resident; Internal Medicine Residency Program, Maricopa Medical Center, Phoenix, Ariz

An 81-year-old woman who had been confined to a nursing home for several years with Alzheimer's dementia, type 2 diabetes, and recurrent urinary tract infections, was sent to the hospital with fever, obtundation, and decreased urine output. Physical examination revealed: blood pressure, 110/70 mm Hg; heart rate, 110 beats/min; and oral temperature, 38.4 C. Her mucous membranes were dry; her abdomen was distended, with a palpable, 15 x 15 cm smooth, round mass. An x-ray of the abdomen was ordered (Figure). Use of a Foley catheter resulted in prompt diuresis of 1800 mL of foul-smelling, cloudy urine.

What's the Diagnosis?

• Volvulus of the sigmoid colon
• Ruptured viscus
• Emphysematous cystitis
• Enterovesicular fistula

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