The Quizzes about Abdominal and Pelvic Pain – Part 1 (20 test)

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Question 1

An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing The note from the facility states that the patient is complaining of abdominal pain, having already vomited once. Her vital signs in the ED are temperature 100.1°F, blood pressure (BP) 105/75 mm Hg, heart rate (HR) 95 beats per minute, and respiratory rate (RR) 18 breaths per minute. You examine the patient and focus on her abdomen. Considering that the patient has not stopped moaning in pain since arriving to the ED, you are surprised to find that her abdomen is soft on palpation. You decide to order an abdominal radiographic series. Which of the findings on plain abdominal film is strongly suggestive of mesenteric infarction?

A	Sentinel loop of bowel
B	No gas in the rectum
C	Presence of an ileus
D	Pneumatosis intestinalis
E	Air fluid levels

Question 1 Explanation:

There is a high suspicion that this patient has mesenteric ischemia, secondary to a thromboembolism from her atrial fibrillation. The typical patient with mesenteric ischemia may initially present with “pain that is out of proportion to the examination” (ie, although the patient is in pain, the abdomen is neither rigid, nor significantly tender on physical examination). Abdominal distention and peritoneal signs are late findings and signal the presence of bowel infarction. Plain abdominal radiographs are usually obtained early on in the workup. Although rare, the finding of gas in either the bowel wall (pneumatosis intestinalis) or in the portal venous system is strongly suggestive of intestinal infarct. This is a surgical emergency! (a, b, c, and e) These are possible findings on radiography for patients with bowel infarction, although less sensitive and specific for infarction compared to pneumatosis intestinalis.

Question 2

A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal They were at a res- taurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with tem- peratures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?

A	Parasites
B	Viruses
C	Enterotoxin-producing bacteria
D	Invasive bacteria

Question 2 Explanation:

Viral diarrheal diseases are responsible for the majority of all acute episodes of diarrhea. Rotavirus, typically a disease of young children and Norwalk virus are the most frequent etiologic agents. In addition, enteric adenovirus is a common cause of gastroenteritis. Though dehydration is a common complication, these illnesses are usually self-limited, requiring only supportive care. (c, d, and e) Bacterial causes of diarrheal disease comprise approximately 20% of all cases. (a) Parasitic causes are much more common outside of the United States.

Question 3

A 49-year-old man presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days The patient states that he usually drinks a six pack of beer daily, but increased his drinking to 2 six packs daily over the last week because of pressures at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125/75 mm Hg, HR is 105 beats per minute, and RR is 20 breaths per minute. You note generalized abdominal tenderness on examination. Laboratory results reveal the following:

White blood cells (WBC) 9000/mL Sodium 131 mEq/L Hematocrit 48% Potassium 3.5 mEq/L Platelets 210/mL Chloride 101 mEq/L Aspartate transaminase (AST) 85 U/L Bicarbonate 10 mEq/L Alanine transaminase (ALT) 60 U/L Blood urea nitrogen (BUN) 9 mg/dL Alkaline phosphatase 75 U/L Creatinine 0.5 mg/dL Total bilirubin 0.5 mg/dL Glucose 190 mg/dL Lipase 40 IU Nitroprusside test weakly positive for ketones Which of the following is the mainstay of therapy for patients with this condition?

A	Normal saline (NS) solution
B	Half normal saline (½ NS)
C	Glucose solution (D5W)
D	Solution containing both saline and glucose (D5/NS or D5 ½ NS)
E	The type of solution is irrelevant

Question 3 Explanation:

The patient’s presentation is consistent with alcoholic ketoacidosis (AKA). This is an acute metabolic acidosis that typically occurs in people who (1) chronically abuse alcohol and have a recent history of binge drinking, (2) have had little or no recent food intake, and (3) have had persistent vomiting. AKA is characterized by elevated serum ketone levels and a high anion gap (↑AG = Na – [HCO3 + Cl] > 12). A concomitant metabolic alkalosis is common, secondary to vomiting and volume depletion. AKA is the result of (1) starvation with glycogen depletion and counterregulatory hormone production; (2) a raised NADH/NAD+ ratio (related to the metabolism of ethanol); and (3) volume depletion, resulting in ketogenesis. The typical symptoms and physical findings relate to volume depletion and chronic alcohol abuse and include nausea, vomiting, abdominal pain, and/or hematemesis. The fruity odor of ketones may be present on the patient’s breath. The patient’s mental status may be impaired. Also associated with the presentation are dyspnea, tremulousness, and dizziness. Rarely do patients present with muscle pain, fever, diarrhea, syncope, seizure, or melena. In AKA, the β-hydroxybutyrate (β-OH)/acetyl acetate (AcAc) formation ratio is 5:1. The nitroprusside reaction (Acetest) may be negative or only weakly positive for serum ketones because nitroprusside reacts with AcAc, but not with β-OH. Therefore, ketosis may be more severe than would be inferred from a nitroprusside reaction alone. Once the diagnosis of alcoholic ketoacidosis is established, the mainstay of treatment is (b) hydration with 5% dextrose in normal saline (D5NS or ½ NS). With initial therapy, ketone formation shifts toward the production of AcAc so that measured ketone levels rise, although β-OH levels decrease. Carbohydrate and fluid replacement reverse the pathophysiologic derangements that lead to AKA by increasing serum insulin levels and suppressing the release of glucagon and other counterregulatory hormones. Dextrose stimulates the oxidation of NADH and aids in normalizing the NADH/NAD+ ratio. As additional treatment, thiamine supplementation should be given as prophylaxis against Wernicke encephalopathy. In general, exogenous insulin is contraindicated in the treatment of AKA because it may cause life-threatening hypoglycemia in patients with depleted glycogen stores. Fluids alone (a, b, and c) do not correct AKA as quickly as fluids and carbohydrates combined, thus making the type of solution quite relevant (e) to managing this patient indeed.

Question 4

As you palpate the right upper quadrant (RUQ) of a 38-year-old woman’s abdomen, you notice that she stops her inspiration for a brief moment. During the history, the patient states that over the last 2 days she gets pain in her RUQ that radiates to her back shortly after Her vitals include a temperature of 100.4°F, HR of 95 beats per minute, BP of 130/75 mm Hg, and RR of 16 breaths per minute. What is the initial diag- nostic modality of choice for this disorder?

A	Plain film radiograph
B	Computed tomography (CT) scan
C	Magnetic resonance imaging (MRI)
D	Radioisotope cholescintigraphy (HIDA scan)
E	Ultrasonography

Question 4 Explanation:

The patient’s history and physical examination is consistent with acute cholecystitis. Because of the poor predictive value of the history, physical and laboratory findings in cholecystitis, the most important test for diagnosis is a strong clinical suspicion and ultrasound imaging. It is rapid and noninvasive. Ultrasound may show the presence of gallstones as small as 2 mm, gallbladder wall thickening and distention, and pericholecystic fluid. (b) CT scanning may be useful when there are other intra-abdominal disorders in consideration. However, the sensitivity of a CT is less than that of ultrasound when diagnosing acute cholecystitis. (c) MRI usually has no role in the diagnosis of acute cholecystitis. (d) Radioisotope cholescintigraphy (HIDA scan) has a higher sensitivity and specificity than ultrasound making it the most accurate study for cholecystitis; however, it is reserved for cases where ultrasound is negative or equivocal. (a) Plain film radiographs demonstrate stones in the gallbladder only less than 25% of the time.

Question 5

A 31-year-old man from Florida presents to the ED complaining of severe pain that starts in his left flank and radiates to his The pain lasts for about 1 hour and then improves. He had similar pain last week that resolved spontaneously. He noted some blood in his urine this morn- ing. His BP is 145/75 mm Hg, HR is 90 beats per minute, temperature is 98.9°F, and his RR is 24 breaths per minute. His abdomen is soft and non- tender. As you examine the patient, he vomits and has trouble lying still in his stretcher. Which of the following is the most appropriate next step in management?

A	Call surgery consult to evaluate the patient for appendicitis.
B	Order an abdominal CT.
C	Start intravenous (IV) fluids and administer an IV nonsteroidal anti-inflamma- tory drug (NSAID) and antiemetic.
D	Perform an ultrasound to evaluate for an abdominal aortic aneurysm (AAA).
E	Perform an ultrasound to evaluate for testicular torsion.

Question 5 Explanation:

The patient’s history of colicky flank pain that radiates to the groin and hematuria is consistent with a ureteral stone. Adequate analgesia is critical in treating a patient with a ureteral stone. Intravenous ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is frequently administered as a first-line analgesic, but morphine may be necessary for continued pain. In addition to their analgesia, NSAIDs decrease ureterospasm and renal capsular pressure in the obstructed kidney. Antiemetics, such as metoclopramide, help with the nausea and vomiting. (a) Appendicitis is unlikely with a soft, nontender abdomen and no fever. An abdominal CT (b) will probably be necessary, but the patient’s pain needs to be controlled first. An abdominal aortic aneurysm (d) can present with flank pain, however it is very rare in a 31-year-old man. Testicular torsion (e) should always be considered in a patient with groin pain. In this case, a stone is more consistent with the history.

Question 6

A 67-year-old man is brought to the ED by emergency medical service (EMS). His wife states that the patient was doing his usual chores around the house when all of a sudden he started complaining of severe abdominal pain. He has a past medical history of coronary artery disease and hyper- tension. His BP is 85/70 mm Hg, HR is 105 beats per minute, temperature is 9°F, and his RR is 18 breaths per minute. On physical examination, he is diaphoretic and in obvious pain. Upon palpating his abdomen, you feel a large pulsatile mass. An electrocardiogram (ECG) reveals sinus tachycardia. You place the patient on a monitor, administer oxygen, insert two large- bore IVs, and send his blood to the laboratory. His BP does not improve after a 1-L fluid bolus. Which of the following is the most appropriate next step in management?

A	Order a CT scan to evaluate his aorta.
B	Call the angiography suite and have them prepare the room for the patient.
C	Order a portable abdominal radiograph.
D	Call surgery and have them prepare the operating room (OR) for an exploratory laparotomy.
E	Call the cardiac catheterization laboratory to prepare for stent insertion.

Question 6 Explanation:

The classic triad of a ruptured abdominal aortic aneurysm (AAA) is pain, hypotension, and a pulsatile abdominal mass. Sometimes patients have only one or two of the components and occasionally may have none. Most patients who are diagnosed with AAA are asymptomatic. However, rupture is often the first manifestation of an AAA. Most patients with a ruptured AAA experience pain in the abdomen, back, or flank. It is usually acute in onset and severe. Approximately 20% of the time, patients present to the ED with syncope. Patients with a ruptured AAA are unstable until their aorta is cross clamped in the OR. Therefore, any hemodynamically unstable patient with a diagnosed or strongly suspected AAA should be taken immediately to the OR.(a) A CT scan is excellent for diagnosing an AAA in stable patients. (b) Angiography has no role in the emergent evaluation of a patient suspected of a ruptured AAA. (c) An abdominal radiograph can aid in the diagnosis of an AAA. However, when there is high clinical suspicion and the patient is hemodynamically unstable, the patient should be brought to the OR. (e) The patient is not complaining of chest pain and his ECG is not consistent with an acute coronary event. Therefore, cardiac catheterization is not required.

Question 7

A 57-year-old woman presents to the ED with a basin in her hand and actively You insert an IV catheter, start IV fluids, and adminis- ter an antiemetic agent. The patient feels much better but also complains of severe crampy abdominal pain that comes in waves. You examine her abdomen and note that it is distended and that there is a small midline scar in the lower abdomen. Upon auscultation, you hear high-pitched noises that sound like “tinkles.” Palpation elicits pain in all four quadrants but no rebound tenderness. She is guaiac negative. Which of the following is the most common cause of this patient’s presentation?

A	Travel to Mexico
B	Ethanol abuse
C	Hysterectomy
D	Hernia
E	Constipation

Question 7 Explanation:

The patient presents with the clinical findings of SBO: vomiting, intermittent crampy abdominal pain, abdominal distention, hyperactive bowel sounds, and general tenderness. The most common cause of SBO in developed countries is postoperative adhesions, responsible for more than 50% of all SBO. There is a particularly high incidence of SBO after gynecologic surgeries, such as a hysterectomy. A common mnemonic for the causes of bowel obstruction is ABC: Adhesions, Bulges (hernia), and Cancer. Hernias (d) are the second most common cause of obstruction. Traveling to Mexico (a) may give you diarrhea and abdominal pain from enteritis. Ethanol abuse (b) can lead to abdominal pain because of many causes, such as gastritis. Constipation (e) will not produce the hyperactive bowel sounds as seen in obstruction.

Question 8

An undomiciled 41-year-old man walks into the ED complaining of abdominal pain, nausea, and He tells you that he has been drink- ing beer continuously over the previous 18 hours. On examination, his vitals are BP 150/75 mm Hg, HR 104 beats per minute, RR 16 breaths per minute, oxygen saturation 97% on room air, temperature of 99.1°F rec- tally, and finger stick glucose 81 mg/dL. The patient is alert and oriented, his pupils anicteric. You notice gynecomastia and spider angiomata. His abdomen is soft but tender in the RUQ. Laboratory tests reveal an AST of 212 U/L, ALT 170 U/L, alkaline phosphatase of 98 U/L, total bilirubin of

1.9 mg/dL, international normalized ratio (INR) of 1.3, WBC 12,000/mL. Urinalysis shows 1+ protein. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?

A	Place a nasogastric tube in the patient’s stomach to remove any remaining ethanol.
B	Order a HIDA scan to evaluate for acute cholecystitis.
C	Administer hepatitis B immune globulin.
D	Send viral hepatitis titers.
E	Provide supportive care by correcting any fluid and electrolyte imbalances.

Question 8 Explanation:

The patient’s clinical presentation is consistent with alcoholic hepatitis, which is a potentially severe form of alcohol-induced liver disease. Most people remain subclinical, but the presentation ranges from nausea and vomiting to fulminant hepatitis and liver failure. Laboratory tests usually reveal moderate elevations of AST and ALT. Usually in alcoholic hepatitis, the AST is greater than the ALT (think “scotch” and “tonic” for AST > ALT). The patient exhibits stigmata of chronic alcohol disease seen by gynecomastia and spider angiomata. The management is principally supportive, with correction of any fluid or electrolyte imbalances, paying special attention to blood glucose (ethanol can suppress gluconeogenesis) and magnesium. Thiamine may also be deficient in chronic alcoholics. Suctioning the patient’s stomach with a nasogastric tube (a) is not indicated and should not be performed. A HIDA scan (b) is the most accurate test for establishing the diagnosis of cholecystitis. However, before an HIDA is performed, individuals with suspected cholecystitis should undergoAbdominal and Pelvic Pain Answers 91 ultrasound scanning. Unless this is a known needle stick or mucosal exposure, hepatitis immune globulin (c) is not acutely indicated. Viral hepatitis titers (d) can be drawn as an outpatient if suspicious for a viral infection.

Question 9

A 48-year-old man with a past medical history of hepatitis C and cir- rhosis presents to the ED complaining of acute-onset abdominal pain and His BP is 118/75 mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, temperature is 101.2°F rectally, and oxygen saturation is 97% on room air. His abdomen is distended, and diffusely tender. You decide to perform a paracentesis and retrieve 1 L of cloudy fluid. Laboratory analysis of the fluid shows a neutrophil count of 550 cells/mm3. Which of the fol- lowing is the most appropriate choice of treatment?

A	Metronidazole
B	Vancomycin
C	Sulfamethoxazole/trimethoprim (SMX/TMP)
D	Neomycin and lactulose
E	Cefotaxime

Question 9 Explanation:

Analysis of abdominal fluid and clinical presentation are consistent with spontaneous bacterial peritonitis (SBP). It is recommended to start antibiotic treatment for SBP if the neutrophil count is greater than 250 cells/mm3. Causative organisms include gram-negative enterococcus such as E coli and Klebsiella, as well as Streptococcus sp, and Streptococcus pneumoniae. Therefore, the most appropriate antibiotic for treatment is a third-generation cephalosporin, such as cefotaxime.

Question 10

A 24-year-old man woke up from sleep 1 hour ago with severe pain in his right He states that he is sexually active with multiple partners. On examination, the right scrotum is swollen, tender, and firm. You cannot elicit a cremasteric reflex. His BP is 145/75 mm Hg, HR is 103 beats per minute, RR is 14 breaths per minute, temperature is 98.9°F, and oxygen saturation is 99% on room air. Which of the following is the most appro- priate next step in management?

A	Administer one dose of ceftriaxone and doxycycline for 10 days and have him follow-up with a urologist.
B	Swab his urethra, send a culture for gonorrhea and Chlamydia, and treat if positive.
C	Send a urinalysis and treat for a urinary tract infection (UTI) if positive.
D	Treat the patient for epididymitis and have him return if symptoms persist.
E	Order a statim (STAT) color Doppler ultrasound and urologic consultation.

Question 10 Explanation:

Testicular torsion is a surgical emergency. There are two peak periods in which torsion is likely to occur, the first year of life and at puberty. Manual detorsion can be attempted in most cases while arranging for definitive care. After appropriate analgesia, the anterior testicle should be twisted laterally, like opening a book. Color Doppler ultrasound is the best test of choice in most hospitals. Immediate evaluation and referral to a urologist is essential. Prehn sign (the physical lifting of the testicles relieves the pain of epididymitis but not pain caused by testicular torsion) is a medical diagnostic indicator that was once believed to help determine whether the presenting testicular pain is caused by acute epididymitis or from testicular torsion. Although elevation of the scrotum when differentiating epididymitis from testicular torsion is of clinical value, Prehn sign has been shown to be inferior to Doppler ultrasound to rule out testicular torsion. To administer ceftriaxone and doxycycline (a) and swab his urethra (b) is the correct management for urethritis. A urinalysis (c) should be sent on most patients with scrotal pain but in this case the diagnosis of torsion takes precedence. Although epididymitis (d) and torsion have similar presentations, epididymitis usually has more of a gradual onset, reaching a peak over days. Epididymitis is the most common misdiagnosis of testicular torsion.

Question 11

A 28-year-old man presents to the ED complaining of constant vague, diffuse epigastric He describes having a poor appetite and feeling nauseated ever since eating sushi last night. His BP is 125/75 mm Hg, HR is 96 beats per minute, temperature is 100.5°F, and his RR is 16 breaths per minute. On examination, his abdomen is soft and moderately tender in the right lower quadrant (RLQ). Laboratory results reveal a WBC of 12,000/

mL. Urinalysis shows 1+ leukocyte esterase. The patient is convinced that

this is food poisoning from the sushi and asks for some antacid. Which of the following is the most appropriate next step in management?

A	Order a plain radiograph to look for dilated bowel loops.
B	Administer 40 cc of Maalox and observe for 1 hour.
C	Send the patient for an abdominal ultrasound.
D	Order an abdominal CT scan.
E	Discharge the patient home with ciprofloxacin.

Question 11 Explanation:

Appendicitis is the most common cause of the acute surgical abdomen. It can occur at any age but is most prevalent in the teens and twenties. It is classically described as starting with the vague onset of dull periumbilical pain that migrates to92 Emergency Medicine the RLQ. It is associated with anorexia, nausea, and vomiting. A low-grade fever may develop. You should suspect appendicitis in any patient with RLQ pain. Approximately 90% of patients have a WBC greater than 10,000/ mm3 although, the WBC can be normal in appendicitis. Urinalysis can help differentiate urinary tract disease from acute appendicitis, although a mild pyuria may be seen in appendicitis if the appendix is irritating the ureter. Abdominal CT with IV and oral or rectal contrast is reported to have a sensitivity of up to 100% and specificity of 95%. CT findings of appendicitis include an enlarged appendix (> 6 mm), pericecal inflammation, and the presence of an appendicolith. (a) Dilated loops of bowel are suggestive of bowel obstruction. (b) Many patients who ultimately are diagnosed with appendicitis initially believed they had food poisoning. If there is a low clinical suspicion for appendicitis and gastritis is more likely, than administering an antacid and observation is reasonable. However, any change in clinical examination should be attributed to a more significant process. (c) Abdominal ultrasound is commonly used initially in pregnant women and children with suspected appendicitis. Its sensitivity and specificity approaches 90%, but there may be inadequate studies as a result of body habitus or with a retrocecal appendix. (e) It would be inappropriate to discharge this patient home without first evaluating for appendicitis.

Question 12

A 23-year-old woman presents to the ED in moderate pain in her left lower quadrant (LLQ). She states that the pain began suddenly and is asso- ciated with nausea and She had a bout of diarrhea yesterday. This is the second time this month that she experienced pain in this location, however, never with this severity. Her BP is 120/75 mm Hg, HR is 101 beats per minute, temperature is 99.5°F, and RR is 18 breaths per minute. She has a tender LLQ on abdominal examination and a tender adnexa on pelvic examination. Which of the following is the most appropriate diagnostic test for the patient?

A	CT scan
B	MRI
C	X-ray
D	Doppler ultrasound
E	Laparoscopy

Question 12 Explanation:

The patient’s clinical picture is consistent with ovarian torsion. This phenomenon is most common in women in their mid-twenties. It is caused by the ovary twisting on its stalk, which leads to occlusion of venous draining from the ovary. This leads to ovarian edema, hemorrhage, and necrosis. Most occur in the presence of an enlarged ovary (ie, as a result of cyst, abscess, or tumor). Patients may give a history of similar pain that resolved spontaneously. The first choice to diagnose ovarian torsion is with Doppler ultrasound to demonstrate decreased or absent blood flow to the ovary. It can also identify an ovarian mass. If suspicion is high for ovarian torsion, the patient may immediately undergo laparoscopy, which is diagnostic and potentially therapeutic. (a) CT scan may be necessary if the Doppler studies are equivocal. However, if torsion is suspected, the individual should undergo a laparoscopy, which is the definitive diagnostic procedure. (b) MRI and (c) x-ray have no role in the diagnosis of ovarian torsion. If there is high enough clinical suspicion, and diagnostic tests are equivocal, laparoscopy (e) can be used to visualize the ovaries in vivo.

Question 13

A 55-year-old man presents to the ED complaining of mild diffuse abdominal He states that he underwent a routine colonoscopy yester- day and was told “everything is fine.” The pain began upon waking up and is associated with some nausea. He denies fever, vomiting, diarrhea, and rectal bleeding. His BP is 143/71 mm Hg, HR is 87 beats per minute, tem- perature is 98.9°F, and RR is 16 breaths per minute. His abdomen is tense but only mildly tender. You order baseline laboratory tests. His chest radio- graph is seen below. Which of the following is the most likely diagnosis?

A	Ascending cholangitis
B	Acute pulmonary edema
C	Acute liver failure
D	Pancreatitis
E	Pneumoperitoneum

Question 13 Explanation:

Potential complications of colonoscopy include hemorrhage, perforation, retroperitoneal abscess, pneumoscrotum, pneumothorax, volvulus, and infection. Perforation of the colon with pneumoperitoneum is usually evident immediately, but can take several hours to manifest. Perforation is usually secondary to intrinsic disease of the colon (eg, diverticulitis) or to vigorous manipulation during colonoscopy. Most patients require immediate laparotomy. However, expectant management is appropriate in some patients with a late presentation (1-2 days later), or without signs of peritonitis. The radiograph in the figure demonstrates air under the diaphragm, which is pathognomonic for pneumoperitoneum. Ascending cholangitis (a) and pancreatitis (d) may occur as a complication from endoscopic retrograde cholangiopancreatography (ERCP). (b) There is no evidence of pulmonary edema in this radiograph. (c) Liver failure with ascites does not cause pneumoperitoneum.

Question 14

A 78-year-old woman is brought to the ED by EMS complaining of vomiting and abdominal pain that began during the night. EMS reports that her BP is 90/50 mm Hg, HR is 110 beats per minute, temperature is 2°F, and RR is 18 breaths per minute. After giving her a 500 mL bolus of NS, her BP is 115/70 mm Hg. During the examination, you notice that her face and chest appear jaundiced. Her lungs are clear to auscultation and you do not appreciate a murmur on cardiac examination. She winces when you palpate her RUQ. An ultrasound reveals dilation of the common bile duct and stones in the gallbladder. What is the most likely diagnosis?

A	Cholecystitis
B	Acute hepatitis
C	Cholangitis
D	Pancreatic cancer
E	Bowel obstruction

Question 14 Explanation:

The patient’s clinical picture is consistent with cholangitis, which is caused by an obstruction of the biliary tract leading to bacterial infection. Obstruction is commonly secondary to a stone, but may be because of malignancy or stricture. Cholangitis is a surgical emergency. The classic triad of physical findings described by Charcot is RUQ pain, fever, and jaundice. Sepsis is a common complication. Sonography may demonstrate intrahepatic or ductal dilation. The presence of stones in the gallbladder suggests obstruction as the etiology. There is overlap in the clinical presentation with cholecystitis (a), however, the presence of jaundice and evidence of dilated common and intrahepatic ducts—which are not characteristic of cholecystitis—is helpful to distinguish it from cholangitis. Acute hepatitis (b) will not have the same sonographic findings seen in cholangitis. Pancreatic cancer (d) can present with jaundice, but it is usually painless. Bowel obstruction (e) generally presents with intermittent crampy abdominal pain, vomiting, and distention.

Question 15

A 23-year-old woman presents to the ED complaining of lower abdominal pain and vaginal spotting for 2 Her menstrual cycle is irregular. She has a history of ovarian cysts and is sexually active but always uses con- doms. Her BP is 115/75 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Which of the following tests should be obtained next?

A	Chlamydia antigen test.
B	-Human chorionic gonadotropin (-hCG).
C	Transvaginal ultrasound.
D	Abdominal radiograph.
E	Observe her abdominal pain, if it resolves discharge her with a diagnosis of menstruation.

Question 15 Explanation:

β-Human chronic gonadotropin (β-hCG) should be obtained in all women of child-bearing age who present with abdominal pain or vaginal bleeding. Diagnostically, it is one of the most important tests in female patients. A positive pregnancy test in the setting of abdominal pain and vaginal bleeding demands that the physician rule out an ectopic pregnancy. Even though the patient states she always uses condoms during intercourse, there is still a small risk of pregnancy. (a) Women with lower abdominal pain and vaginal discharge may have cervicitis or pelvic inflammatory disease and require a Chlamydia antigen test. However, a pelvic examination should be performed first. (c) With a positive pregnancy test, transvaginal ultrasound is the next step in management. This is used to detect an intrauterine pregnancy. If no intrauterine pregnancy is detected, the suspicion for an ectopic pregnancy increases. (d) An abdominal radiograph may be obtained later in the workup, but is not currently indicated. (e) Observation is not an acceptable option in any patient with undifferentiated abdominal pain and vaginal bleeding. It is imperative that the clinician rule out an ectopic pregnancy in this individual.

Question 16

A 71-year-old obese man is brought to the ED complaining of constant left mid quadrant (LMQ) abdominal pain with radiation into his His past medical history is significant for hypertension, peripheral vascular dis- ease, peptic ulcer disease, kidney stones, and gallstones. He smokes a pack of cigarettes and consumes a pint of vodka daily. His BP is 145/80 mm Hg, HR is 90 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Abdominal examination is unremarkable. An ECG is read as sinus rhythm with an HR of 88 beats per minute. An abdominal radiograph reveals normal loops of bowel and curvilinear calcification of the aortic wall. Which of the following is the most likely diagnosis?

A	Biliary colic
B	Nephrolithiasis
C	Pancreatitis
D	Small bowel obstruction (SBO)
E	Abdominal aortic aneurysm

Question 16 Explanation:

he patient presents with multiple risk factors for an AAA: age greater than 60, male gender, hypertension, cigarette smoking, and peripheral artery disease. Classically, AAA presents with constant abdominal pain, often localizing to the left middle or lower quadrant with radiation to the back. Physical examination may reveal a pulsatile abdominal mass. Patients can present unstable if the aneurysm leaks or ruptures requiring emergent management in the OR. Evidence of an AAA is seen on plain radiograph approximately 66% to 75% of the time. The most common findings are curvilinear calcification of the aortic wall or a paravertebral soft tissue mass. Ultrasound and CT are the best diagnostic tools for the stable patient. (a) Biliary colic occurs in the RUQ and usually lasts less than 6 hours. (b) The pain of a kidney stone is usually described as colicky in nature. Pain typically begins in the flank and radiates to the groin. (c) Pancreatitis typically presents with mid-epigastric pain that radiates to the back and is associated with nausea and vomiting. (d) SBO is diagnosed on radiography by evidence of dilated loops of bowel, air-fluid levels, and thickening of the bowel wall.

Question 17

A 51-year-old man presents to the ED complaining of epigastric pain that radiates to his He states that he drinks six packs of beer daily. You suspect he has pancreatitis. His BP is 135/75 mm Hg, HR is 90 beats per minute, temperature is 100.1°F, and his RR is 17 breaths per min- ute. Laboratory results reveal WBC 13,000/mL, hematocrit 48%, platelets 110/mL, amylase 1150 U/L, lipase 1450 IU, lactate dehydrogenase (LDH) 150 U/L, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 105 mEq/L, bicarbonate 23 mEq/L, BUN 15 mg/dL, creatinine 1.1 mg/dL, and glucose 125 mg/dL. Which of the following laboratory values are most specific for pancreatitis?

A	Elevated amylase
B	Hyperglycemia
C	Elevated lipase
D	Elevated LDH
E	Leukocytosis

Question 17 Explanation:

Lipase is a pancreatic enzyme that hydrolyzes triglycerides. In the presence of pancreatic inflammation it increases within 4 to 8 hours and peaks at 24 hours. At five times the upper limits of normal, lipase is 60% sensitive and 100% specific for pancreatitis. The diagnosis is usually made with a lipase of two times the normal limit, thereby increasing its sensitivity (a) Elevations of amylase are approximately 70% specific for the diagnosis of pancreatitis. (b, d, and e) are all laboratory values that are used in the prognosis for pancreatitis, not for its diagnosis.

Question 18

A 51-year-old man describes 1 week of gradually worsening scrotal pain and He is sexually active with his wife. His temperature is 100.1°F, HR 81 beats per minute, BP 140/75 mm Hg, and oxygen satura- tion is 99% on room air. On physical examination, his scrotal skin is warm and erythematous. A cremasteric reflex is present. The posterior left testicle is swollen and tender to touch. Color Doppler ultrasonography demon- strates increased testicular blood flow. Urinalysis is positive for leukocyte esterase. What is the most likely diagnosis?

A	Epididymitis
B	Testicular torsion
C	UTI
D	Testicular tumor
E	Varicocele

Question 18 Explanation:

The patient has epididymitis. It is often difficult to distinguish epididymitis from testicular torsion and the clinician should always rule out torsion first if the diagnosis is in doubt. It is the most common misdiagnosis for testicular torsion. Epididymitis is generally a disease of adult men. The causative organism in men over 35 years is E coli, while C trachomatis and Neisseria gonorrhoeae predominate in men less than 35 years old. The older patient may have a history of gonococcal urethritis (GU) tract manipulation or a history of prostatitis. The onset is usually gradual and urinary tract symptoms may precede the pain. Testicular torsion (b) should always be on the differential for a patient with scrotal pain. However, it is ruled out in this patient by the presence of blood flow on color Doppler. UTIs in men (c), in the absence of trauma or instrumentation, are rare. Scrotal pain is usually not present. Testicular tumors (d) are often mistakenly diagnosed as epididymitis. They usually occur in middle-aged men and have a higher prevalence in patients with cryptorchidism. Color Doppler can often distinguish a tumor from epididymitis. A varicocele (e) is a painless scrotal swelling that is caused by dilation and elongation of the veins of the pampiniform plexus. Varicocele is more common on the left side because the left spermatic vein drains into the left renal vein, whereas the right one drains into the inferior vena cava. Individuals may be asymptomatic or complain of a scrotal pain or heaviness. It is thought that varicoceles may decrease sperm production.

Question 19

A 22-year-old man presents to the ED complaining of dysuria for 3 He states that he has never had this feeling before. He is currently sexually active and uses a condom most of the time. He denies hematuria but notes a yellowish discharge from his urethra. His BP is 120/75 mm Hg, HR is 60 beats per minute, and temperature is 98.9°F. You send a clean catch urinalysis to the laboratory that returns positive for leukocyte esterase and 15 white blood cells per high power field (WBCs/hpf). Which of the fol- lowing is the most appropriate next step in management?

A	41. A 22-year-old man presents to the ED complaining of dysuria for 3 days. He states that he has never had this feeling before. He is currently sexually active and uses a condom most of the time. He denies hematuria but notes a yellowish discharge from his urethra. His BP is 120/75 mm Hg, HR is 60 beats per minute, and temperature is 98.9°F. You send a clean catch urinalysis to the laboratory that returns positive for leukocyte esterase and 15 white blood cells per high power field (WBCs/hpf). Which of the fol- lowing is the most appropriate next step in management?
B	Send urine for culture and administer SMX/TMP orally.
C	Discharge the patient with strict instructions to return if his symptoms worsen.
D	Order a CT scan to evaluate for a kidney stone.
E	Have him follow-up immediately with a urologist to evaluate for testicular cancer.

Question 19 Explanation:

Dysuria in young men is almost always because of urethritis, which is commonly caused by a sexually transmitted disease. Urethritis is classically divided into gonococcal (GU) and nongonococcal (NGU) types. GU is caused by N gonorrhoeae, while the major pathogen in NGU is C trachomatis. Nearly all men with GU have purulent urethral discharge. NGU may be asymptomatic or with a yellow, mucopurulent discharge. It was demonstrated in multiple studies that the two pathogens coexist in men with urethritis up to 50% of the time. Therefore, antibiotics should be directed at eliminating both organisms. A third-generation cephalosporin or ciprofloxacin as a one-time dose is used to treat GU. Common antibiotics used to treat NGU include azithromycin96 Emergency Medicine as a single dose and doxycycline or erythromycin for 7 days. In addition, the patient should refer all of their sexual partners for evaluation and treatment. (d and e) There is no clinical suspicion for a kidney stone or testicular cancer. (b) This choice might be correct if you suspect a patient has UTI. However, a young man with dysuria and urethral discharge needs to be treated for a sexually transmitted disease. (c) The patient should not be discharged prior to treatment and culture.

Question 20

A 40-year-old woman presents to the ED complaining of fever and 1 day of increasingly severe pain in her She denies nausea or vomit- ing and has no history of fatty food intolerance. The patient returned from a trip to Mexico 6 months ago. About 2 weeks ago she experienced inter- mittent diarrhea with blood-streaked mucus. Her BP is 130/80 mm Hg, HR is 107 beats per minute, temperature is 102°F, and RR is 17 breaths per minute. Physical examination reveals decreased breath sounds over the right lung base. Abdominal examination shows tenderness to percussion over the RUQ and normal active bowel sounds. There is no Murphy sign. Her WBC is 20,500/mL. Chest radiograph reveals a small right-pleural effu- sion. Which of the following is the most likely diagnosis?

A	Amebic abscess
B	Cholecystitis
C	Cryptosporidium
D	Enterobiasis
E	Pyogenic abscess

Question 20 Explanation:

Amebic abscesses are common in countries with tropical and subtropical climates and areas with poor sanitation. Entamoeba histolytica causes an intestinal infection, and the liver is seeded via the portal system. The clinical presentation includes abdominal tenderness in the RUQ, leukocytosis, and fever. Diagnosis is supported by identifying a pathogenic protozoan in the stool. Management consists of supportive care and administering metronidazole. If medical therapy is unsuccessful, percutaneous catheter drainage is required. (b) Cholecystitis will present with fever, leukocytosis, and pain. A Murphy sign is usually present. (c) Cryptosporidium is the most common cause of chronic diarrhea in individuals with AIDS. Patients present with profuse watery diarrhea, abdominal cramping, anorexia, nausea, and flatulence. Symptoms persist in the immunocompetent for approximately 1 to 3 weeks and are self-limited. Dehydration is common. There was a cryptosporidium outbreak in Milwaukee, Wisconsin in 1993 after a water purification plant was contaminated. More than 100 people died, among them mostly the elderly and immunocompromised. (d) Patients with enterobiasis or pinworms complain of itching in the anal region, particularly at night, as the adult worm lays eggs in the anus. (e) Pyogenic abscess is the most common type of liver abscess; however, the history of travel, and lack of primary source for the pyogenic abscess make it less likely a diagnosis. Underlying biliary disease with extrahepatic biliary obstruction leading to ascending cholangitis and abscess formation is the most common cause and is usually associated with choledocholithiasis, benign and malignant tumors, or postsurgical strictures.

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1. An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing The note from the facility states that the patient is complaining of abdominal pain, having already vomited once. Her vital signs in the ED are temperature 100.1°F, blood pressure (BP) 105/75 mm Hg, heart rate (HR) 95 beats per minute, and respiratory rate (RR) 18 breaths per minute. You examine the patient and focus on her abdomen. Considering that the patient has not stopped moaning in pain since arriving to the ED, you are surprised to find that her abdomen is soft on palpation. You decide to order an abdominal radiographic series. Which of the findings on plain abdominal film is strongly suggestive of mesenteric infarction?

Sentinel loop of bowel
No gas in the rectum
Presence of an ileus
Pneumatosis intestinalis
Air fluid levels

2. A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal They were at a res- taurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with tem- peratures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?

Parasites
Viruses
Enterotoxin-producing bacteria
Anaerobic bacteria
Invasive bacteria

3. A 49-year-old man presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days The patient states that he usually drinks a six pack of beer daily, but increased his drinking to 2 six packs daily over the last week because of pressures at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125/75 mm Hg, HR is 105 beats per minute, and RR is 20 breaths per minute. You note generalized abdominal tenderness on examination. Laboratory results reveal the following:

White blood cells (WBC) 9000/mL Sodium 131 mEq/L

Hematocrit 48% Potassium 3.5 mEq/L

Platelets 210/mL Chloride 101 mEq/L

Aspartate transaminase (AST) 85 U/L Bicarbonate 10 mEq/L

Alanine transaminase (ALT) 60 U/L Blood urea nitrogen (BUN) 9 mg/dL

Alkaline phosphatase 75 U/L Creatinine 0.5 mg/dL

Total bilirubin 0.5 mg/dL Glucose 190 mg/dL

Lipase 40 IU Nitroprusside test weakly positive for ketones

Which of the following is the mainstay of therapy for patients with this condition?

Normal saline (NS) solution
Half normal saline (½ NS)
Glucose solution (D5W)
Solution containing both saline and glucose (D5/NS or D5 ½ NS)
The type of solution is irrelevant

4. As you palpate the right upper quadrant (RUQ) of a 38-year-old woman’s abdomen, you notice that she stops her inspiration for a brief moment. During the history, the patient states that over the last 2 days she gets pain in her RUQ that radiates to her back shortly after Her vitals include a temperature of 100.4°F, HR of 95 beats per minute, BP of 130/75 mm Hg, and RR of 16 breaths per minute. What is the initial diag- nostic modality of choice for this disorder?

Plain film radiograph
Computed tomography (CT) scan
Magnetic resonance imaging (MRI)
Radioisotope cholescintigraphy (HIDA scan)
Ultrasonography

5. A 31-year-old man from Florida presents to the ED complaining of severe pain that starts in his left flank and radiates to his The pain lasts for about 1 hour and then improves. He had similar pain last week that resolved spontaneously. He noted some blood in his urine this morn- ing. His BP is 145/75 mm Hg, HR is 90 beats per minute, temperature is 98.9°F, and his RR is 24 breaths per minute. His abdomen is soft and non- tender. As you examine the patient, he vomits and has trouble lying still in his stretcher. Which of the following is the most appropriate next step in management?

Call surgery consult to evaluate the patient for appendicitis.
Order an abdominal CT.
Start intravenous (IV) fluids and administer an IV nonsteroidal anti-inflamma- tory drug (NSAID) and antiemetic.
Perform an ultrasound to evaluate for an abdominal aortic aneurysm (AAA).
Perform an ultrasound to evaluate for testicular torsion.

6. A 67-year-old man is brought to the ED by emergency medical service (EMS). His wife states that the patient was doing his usual chores around the house when all of a sudden he started complaining of severe abdominal pain. He has a past medical history of coronary artery disease and hyper- tension. His BP is 85/70 mm Hg, HR is 105 beats per minute, temperature is 9°F, and his RR is 18 breaths per minute. On physical examination, he is diaphoretic and in obvious pain. Upon palpating his abdomen, you feel a large pulsatile mass. An electrocardiogram (ECG) reveals sinus tachycardia. You place the patient on a monitor, administer oxygen, insert two large- bore IVs, and send his blood to the laboratory. His BP does not improve after a 1-L fluid bolus. Which of the following is the most appropriate next step in management?

Order a CT scan to evaluate his aorta.
Call the angiography suite and have them prepare the room for the patient.
Order a portable abdominal radiograph.
Call surgery and have them prepare the operating room (OR) for an exploratory laparotomy.
Call the cardiac catheterization laboratory to prepare for stent insertion.

7. A 57-year-old woman presents to the ED with a basin in her hand and actively You insert an IV catheter, start IV fluids, and adminis- ter an antiemetic agent. The patient feels much better but also complains of severe crampy abdominal pain that comes in waves. You examine her abdomen and note that it is distended and that there is a small midline scar in the lower abdomen. Upon auscultation, you hear high-pitched noises that sound like “tinkles.” Palpation elicits pain in all four quadrants but no rebound tenderness. She is guaiac negative. Which of the following is the most common cause of this patient’s presentation?

Travel to Mexico
Ethanol abuse
Hysterectomy
Hernia
Constipation

8. An undomiciled 41-year-old man walks into the ED complaining of abdominal pain, nausea, and He tells you that he has been drink- ing beer continuously over the previous 18 hours. On examination, his vitals are BP 150/75 mm Hg, HR 104 beats per minute, RR 16 breaths per minute, oxygen saturation 97% on room air, temperature of 99.1°F rec- tally, and finger stick glucose 81 mg/dL. The patient is alert and oriented, his pupils anicteric. You notice gynecomastia and spider angiomata. His abdomen is soft but tender in the RUQ. Laboratory tests reveal an AST of 212 U/L, ALT 170 U/L, alkaline phosphatase of 98 U/L, total bilirubin of 1.9 mg/dL, international normalized ratio (INR) of 1.3, WBC 12,000/mL. Urinalysis shows 1+ protein. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?

Place a nasogastric tube in the patient’s stomach to remove any remaining ethanol.
Order a HIDA scan to evaluate for acute cholecystitis.
Administer hepatitis B immune globulin.
Send viral hepatitis titers.
Provide supportive care by correcting any fluid and electrolyte imbalances.

9. A 48-year-old man with a past medical history of hepatitis C and cir- rhosis presents to the ED complaining of acute-onset abdominal pain and His BP is 118/75 mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, temperature is 101.2°F rectally, and oxygen saturation is 97% on room air. His abdomen is distended, and diffusely tender. You decide to perform a paracentesis and retrieve 1 L of cloudy fluid. Laboratory analysis of the fluid shows a neutrophil count of 550 cells/mm3. Which of the fol- lowing is the most appropriate choice of treatment?

Metronidazole
Vancomycin
Sulfamethoxazole/trimethoprim (SMX/TMP)
Neomycin and lactulose
Cefotaxime

10. A 24-year-old man woke up from sleep 1 hour ago with severe pain in his right He states that he is sexually active with multiple partners. On examination, the right scrotum is swollen, tender, and firm. You cannot elicit a cremasteric reflex. His BP is 145/75 mm Hg, HR is 103 beats per minute, RR is 14 breaths per minute, temperature is 98.9°F, and oxygen saturation is 99% on room air. Which of the following is the most appro- priate next step in management?

Administer one dose of ceftriaxone and doxycycline for 10 days and have him follow-up with a urologist.
Swab his urethra, send a culture for gonorrhea and Chlamydia, and treat if positive.
Send a urinalysis and treat for a urinary tract infection (UTI) if positive.
Treat the patient for epididymitis and have him return if symptoms persist.
Order a statim (STAT) color Doppler ultrasound and urologic consultation.

11. A 28-year-old man presents to the ED complaining of constant vague, diffuse epigastric He describes having a poor appetite and feeling nauseated ever since eating sushi last night. His BP is 125/75 mm Hg, HR is 96 beats per minute, temperature is 100.5°F, and his RR is 16 breaths per minute. On examination, his abdomen is soft and moderately tender in the right lower quadrant (RLQ). Laboratory results reveal a WBC of 12,000/mL. Urinalysis shows 1+ leukocyte esterase. The patient is convinced that this is food poisoning from the sushi and asks for some antacid. Which of the following is the most appropriate next step in management?

Order a plain radiograph to look for dilated bowel loops.
Administer 40 cc of Maalox and observe for 1 hour.
Send the patient for an abdominal ultrasound.
Order an abdominal CT scan.
Discharge the patient home with ciprofloxacin.

12. A 23-year-old woman presents to the ED in moderate pain in her left lower quadrant (LLQ). She states that the pain began suddenly and is asso- ciated with nausea and She had a bout of diarrhea yesterday. This is the second time this month that she experienced pain in this location, however, never with this severity. Her BP is 120/75 mm Hg, HR is 101 beats per minute, temperature is 99.5°F, and RR is 18 breaths per minute. She has a tender LLQ on abdominal examination and a tender adnexa on pelvic examination. Which of the following is the most appropriate diagnostic test for the patient?

CT scan
MRI
X-ray
Doppler ultrasound
Laparoscopy

13. A 55-year-old man presents to the ED complaining of mild diffuse abdominal He states that he underwent a routine colonoscopy yester- day and was told “everything is fine.” The pain began upon waking up and is associated with some nausea. He denies fever, vomiting, diarrhea, and rectal bleeding. His BP is 143/71 mm Hg, HR is 87 beats per minute, tem- perature is 98.9°F, and RR is 16 breaths per minute. His abdomen is tense but only mildly tender. You order baseline laboratory tests. His chest radio- graph is seen below. Which of the following is the most likely diagnosis?

Ascending cholangitis
Acute pulmonary edema
Acute liver failure
Pancreatitis
Pneumoperitoneum

14. A 78-year-old woman is brought to the ED by EMS complaining of vomiting and abdominal pain that began during the night. EMS reports that her BP is 90/50 mm Hg, HR is 110 beats per minute, temperature is 2°F, and RR is 18 breaths per minute. After giving her a 500 mL bolus of NS, her BP is 115/70 mm Hg. During the examination, you notice that her face and chest appear jaundiced. Her lungs are clear to auscultation and you do not appreciate a murmur on cardiac examination. She winces when you palpate her RUQ. An ultrasound reveals dilation of the common bile duct and stones in the gallbladder. What is the most likely diagnosis?

Cholecystitis
Acute hepatitis
Cholangitis
Pancreatic cancer
Bowel obstruction

15. A 23-year-old woman presents to the ED complaining of lower abdominal pain and vaginal spotting for 2 Her menstrual cycle is irregular. She has a history of ovarian cysts and is sexually active but always uses con- doms. Her BP is 115/75 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Which of the following tests should be obtained next?

Chlamydia antigen test.
b-Human chorionic gonadotropin (b-hCG).
Transvaginal ultrasound.
Abdominal radiograph.
Observe her abdominal pain, if it resolves discharge her with a diagnosis of menstruation.

16. A 71-year-old obese man is brought to the ED complaining of constant left mid quadrant (LMQ) abdominal pain with radiation into his His past medical history is significant for hypertension, peripheral vascular dis- ease, peptic ulcer disease, kidney stones, and gallstones. He smokes a pack of cigarettes and consumes a pint of vodka daily. His BP is 145/80 mm Hg, HR is 90 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Abdominal examination is unremarkable. An ECG is read as sinus rhythm with an HR of 88 beats per minute. An abdominal radiograph reveals normal loops of bowel and curvilinear calcification of the aortic wall. Which of the following is the most likely diagnosis?

Biliary colic
Nephrolithiasis
Pancreatitis
Small bowel obstruction (SBO)
Abdominal aortic aneurysm

17. A 51-year-old man presents to the ED complaining of epigastric pain that radiates to his He states that he drinks six packs of beer daily. You suspect he has pancreatitis. His BP is 135/75 mm Hg, HR is 90 beats per minute, temperature is 100.1°F, and his RR is 17 breaths per min- ute. Laboratory results reveal WBC 13,000/mL, hematocrit 48%, platelets 110/mL, amylase 1150 U/L, lipase 1450 IU, lactate dehydrogenase (LDH) 150 U/L, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 105 mEq/L, bicarbonate 23 mEq/L, BUN 15 mg/dL, creatinine 1.1 mg/dL, and glucose 125 mg/dL. Which of the following laboratory values are most specific for pancreatitis?

Elevated amylase
Hyperglycemia
Elevated lipase
Elevated LDH
Leukocytosis

18. A 51-year-old man describes 1 week of gradually worsening scrotal pain and He is sexually active with his wife. His temperature is 100.1°F, HR 81 beats per minute, BP 140/75 mm Hg, and oxygen satura- tion is 99% on room air. On physical examination, his scrotal skin is warm and erythematous. A cremasteric reflex is present. The posterior left testicle is swollen and tender to touch. Color Doppler ultrasonography demon- strates increased testicular blood flow. Urinalysis is positive for leukocyte esterase. What is the most likely diagnosis?

Epididymitis
Testicular torsion
UTI
Testicular tumor
Varicocele

19. A 22-year-old man presents to the ED complaining of dysuria for 3 He states that he has never had this feeling before. He is currently sexually active and uses a condom most of the time. He denies hematuria but notes a yellowish discharge from his urethra. His BP is 120/75 mm Hg, HR is 60 beats per minute, and temperature is 98.9°F. You send a clean catch urinalysis to the laboratory that returns positive for leukocyte esterase and 15 white blood cells per high power field (WBCs/hpf). Which of the fol- lowing is the most appropriate next step in management?

Send a urethral swab for culture and administer 125 mg ceftriaxone intramuscu- larly and 1 g azithromycin orally.
Send urine for culture and administer SMX/TMP orally.
Discharge the patient with strict instructions to return if his symptoms worsen.
Order a CT scan to evaluate for a kidney stone.
Have him follow-up immediately with a urologist to evaluate for testicular cancer.

20. A 40-year-old woman presents to the ED complaining of fever and 1 day of increasingly severe pain in her She denies nausea or vomit- ing and has no history of fatty food intolerance. The patient returned from a trip to Mexico 6 months ago. About 2 weeks ago she experienced inter- mittent diarrhea with blood-streaked mucus. Her BP is 130/80 mm Hg, HR is 107 beats per minute, temperature is 102°F, and RR is 17 breaths per minute. Physical examination reveals decreased breath sounds over the right lung base. Abdominal examination shows tenderness to percussion over the RUQ and normal active bowel sounds. There is no Murphy sign. Her WBC is 20,500/mL. Chest radiograph reveals a small right-pleural effu- sion. Which of the following is the most likely diagnosis?

Amebic abscess
Cholecystitis
Cryptosporidium
Enterobiasis
Pyogenic abscess

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