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Abdominal and Pelvic Pain-1
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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?
- 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)
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
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?
- Sulfamethoxazole/trimethoprim (SMX/TMP)
- Neomycin and lactulose
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
- Doppler ultrasound
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
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?
- Acute hepatitis
- 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
- 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
- Elevated lipase
- Elevated LDH
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?
- Testicular torsion
- Testicular tumor
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
- Pyogenic abscess