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Abdominal and Pelvic Pain-2
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1. A 59-year-old woman presents to the ED complaining of worsen- ing lower abdominal pain over the previous 3 She describes feel- ing constipated recently and some burning when she urinates. Her BP is 135/75 mm Hg, HR is 89 beats per minute, temperature is 101.2°F, and her RR is 18 breaths per minute. Her abdomen is mildly distended, tender in the LLQ, and positive for rebound tenderness. CT scan is consistent with diverticulitis with a 7-cm abscess. Which of the following is the most appropriate management for this condition?
- Reserve the OR for emergent laparotomy.
- Start treatment with ciprofloxacin and metronidazole and plan for CT-guided draining of the abscess.
- Give an IV dose of ciprofloxacin and have the patient follow up with her primary physician.
- Start treatment with ciprofloxacin and metronidazole and plan for an emergent barium enema.
- Start treatment with ciprofloxacin and metronidazole and prepare for an emer- gent colonoscopy.
2. A 29-year-old man presents to the ED complaining of RLQ pain for 24 He states that the pain first began as a dull feeling around his umbilicus and slowly migrated to his right side. He has no appetite, is nau- seated, and vomited twice. His BP is 130/75 mm Hg, HR is 95 beats per minute, temperature is 100.9°F, and his RR is 16 breaths per minute. His WBC is 14,000/mL. As you palpate the LLQ of the patient’s abdomen, he states that his RLQ is painful. What is the name of this sign?
- Blumberg sign
- Psoas sign
- Obturator sign
- Raynaud sign
- Rovsing sign
3. A 60-year-old man is brought to the ED complaining of generalized crampy abdominal pain that occurs in He has been vomiting inter- mittently over the last 6 hours. His BP is 150/75 mm Hg, HR is 90 beats per minute, temperature is 99.8°F, and his RR is 16 breaths per minute. On abdominal examination you notice an old midline scar across the length of his abdomen that he states was from surgery after a gunshot wound as a teenager. The abdomen is distended with hyperactive bowel sounds and mild tenderness without rebound. An abdominal plain film confirms your diagnosis. Which of the following is the most appropriate next step in management?
- Begin fluid resuscitation, bowel decompression with a nasogastric tube, and request a surgical consult.
- Begin fluid resuscitation, administer broad-spectrum antibiotics, and admit the patient to the medical service.
- Begin fluid resuscitation, give the patient stool softener, and administer a rectal enema.
- Begin fluid resuscitation, administer broad-spectrum antibiotics, and observe the patient for 24 hours.
- Order an abdominal ultrasound, administer antiemetics, and provide pain relief.
4. A 25-year-old G3P1011 presents to the ED with a 6-hour history of worsening lower abdominal pain, mostly in the She also noticed some vaginal spotting this morning. She is nauseated, but did not vomit. Her last menstrual period was 2 months ago, but her cycles are irregular. She is sexually active and has a history of pelvic inflammatory disease. Her BP is 120/75 mm Hg, HR is 95 beats per minute, temperature is 99.2°F, and RR is 16 breaths per minute. Her abdomen is tender in the RLQ. Pelvic examination reveals right adnexal tenderness. Her WBC count is slightly elevated and her b-hCG is positive. After establishing IV access, which of the following is the most appropriate next step in management?
- Call the OR to prepare for laparoscopy.
- Order an emergent CT scan of the abdomen.
- Perform a transvaginal ultrasound.
- Order a urinalysis.
- Swab her cervix and treat for gonorrhea and Chlamydia.
5. A 59-year-old man presents to the ED complaining of vomiting and sharp abdominal pain in the epigastric area that began abruptly this after- He describes feeling nauseated and has no appetite. Laboratory results reveal WBC 18,000/mL, hematocrit 48%, platelets 110/mL, AST 275 U/L, ALT 125 U/L, alkaline phosphatase 75 U/L, amylase 1150 U/L, lipase 1450 IU, LDH 400 U/L, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 20 mEq/L, BUN 20 mg/dL, creatinine 1.5 mg/dL, and glucose 250 mg/dL. Which of the following laboratory results correlate with the poorest prognosis?
- Amylase 950, lipase 1250, LDH 400
- Lipase 1250, LDH 400, bicarbonate 20
- Lipase 1250, creatinine 1.5, potassium 3.5
- WBC 18,000, LDH 400, glucose 250
- WBC 18,000, amylase 950, lipase 1250
6. A 19-year-old woman presents to the ED with 1 hour of acute-onset progressively worsening pain in her RLQ. She developed nausea shortly after the pain and vomited twice over the last She had similar but less severe pain 2 weeks ago that resolved spontaneously. Her BP is 123/78 mm Hg, HR is 99 beats per minute, temperature is 99.1°F, and her RR is 16 breaths per minute. On physical examination, the patient appears uncomfortable, not moving on the gurney. Her abdomen is non- distended, diffusely tender, worst in the RLQ. Pelvic examination reveals a normal-sized uterus and moderate right-sided adnexal tenderness. Labora- tory results reveal WBC 10,000/mL, hematocrit 38%, and a negative uri- nalysis and b-hCG. Pelvic ultrasound reveals an enlarged right ovary with decreased flow. Which of the following is the most appropriate manage- ment for this patient?
- Admit to the gynecology service for observation.
- Administer IV antibiotics and operate once inflammation resolves.
- Attempt manual detorsion.
- Order an abdominal CT.
- Go for immediate laparoscopic surgery.
7. An 18-year-old woman presents to the ED complaining of acute onset of RLQ abdominal She also describes the loss of appetite over the last 12 hours, but denies nausea and vomiting. Her BP is 124/77 mm Hg, HR is 110 beats per minute, temperature is 102.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Abdominal examina- tion reveals lower abdominal tenderness bilaterally. On pelvic examination you elicit cervical motion tenderness and note cervical exudates. Her WBC is 20,500/mL and b-hCG is negative. Which of the following is the most appropriate next step in management?
- Bring her to the OR for an appendectomy.
- Begin antibiotic therapy.
- Perform a culdocentesis.
- Bring her to the OR for immediate laparoscopy.
- Order an abdominal plain film.
8. A 73-year-old man is seen in the ED for abdominal pain, nausea, and vomiting. His symptoms have progressively worsened over the past 2 to 3 The pain is diffuse and comes in waves. He denies fever or chills, but has a history of constipation. He reports no flatus for 24 hours. Physi- cal examination is notable for diffuse tenderness and voluntary guarding. There is no rebound tenderness. An abdominal radiograph is seen below. Which of the following is the most likely diagnosis?
- Large bowel obstruction
- Inflammatory bowel disease
9. A 27-year-old man is seen in the ED for a leak around a surgical G-tube that was placed 2 weeks ago and has been used for enteral feeding for 1 Inspection reveals the tube is pulled out from the stoma, but is still in the cutaneous tissue. The abdomen is soft and nondistended and there are no signs of skin infection. Which of the following is the most appropri- ate next step in management?
- Insert a Foley catheter into the tract and aspirate. If gastric contents are aspirated the tube can be used for feeding.
- Insert a Foley catheter into the tract, instill water-soluble contrast, and obtain an abdominal radiograph prior to using for feeding.
- Remove the tube and admit the patient for observation.
- Remove the tube and immediately obtain a CT scan of the abdomen.
- Return to the OR for closure of gastrotomy and placement of a new tube.
10. A 30-year-old man presents to the ED complaining of sudden onset of abdominal bloating and back pain lasting for 2 The pain woke him up from sleep 2 nights ago. It radiates from his back to his abdomen and down toward his scrotum. He is in severe pain and is vomiting. His temperature is 101.2°F and HR is 107 beats per minute. A CT scan reveals a 9-mm obstructing stone of the left ureter with hydronephrosis. Urinalysis is positive for 2+ blood, 2+ leukocytes, 2+ nitrites, 40 to 50 WBCs, and many bacteria. You administer pain medicine, antiemetics, and antibiotics. Which of the following is the most appropriate next step in management?
- Admit for IV antibiotics and possible surgical removal of stone.
- Observe in ED for another 6 hours to see if stone passes.
- Discharge with antibiotics and pain medicine.
- Discharge patient with instructions to consume large amounts of water.
- Discharge patient with antibiotics, pain medicine, and instructions to drink large amounts of water and cranberry juice.
11. For which of the following patients is an abdominal CT scan contraindicated?
- A 52-year-old man with abdominal pain after blunt trauma, negative focused assessment with sonography for trauma (FAST) examination, BP 125/78 mm Hg, and HR 109 beats per minute
- A 22-year-old woman with RLQ pain, negative b-hCG, temperature 100.6°F
- A 45-year-old man with abdominal pain, temperature 100.5°F, WBC 11,200/mL, BP 110/70 mm Hg, HR 110 beats per minute, and lipase 250 IU
- A 70-year-old man with abdominal pain, an 11-cm pulsatile mass in the epigastrium, BP of 70/50 mm Hg, and HR of 110 beats per minute
- A 65-year-old woman with right flank pain that radiates to her groin, microhematu- ria, BP 165/85 mm Hg, and HR 105 beats per minute
12. You are working in the ED on a Sunday afternoon when four people present with acute-onset vomiting and crampy abdominal They were all at the same picnic and ate most of the same foods. The vomiting began approximately 4 hours into the picnic. They deny having any diarrhea. You believe they may have “food poisoning” so you place IV lines, admin- ister IV fluids, and observe. Over the next few hours, the patients begin to improve, the vomiting stops, and their abdominal pain resolves. Which of the following is the most likely cause of their presentation?
- Scombroid fish poisoning
- Staphylococcal food poisoning
- Clostridium perfringens food poisoning
13. A 63-year-old man is brought to the ED by EMS complaining of severe abdominal pain that began suddenly 6 hours His BP is 145/75 mm Hg and HR is 105 beats per minute and irregular. On examination, you note mild abdominal distention and diffuse abdominal tenderness without guarding. Stool is heme positive. Laboratory results reveal WBC 12,500/mL, hematocrit 48%, and lactate 4.2 U/L. ECG shows atrial fibrillation at a rate of 110. A CT scan is shown below. Which of the following is the most likely diagnosis?
- Abdominal aortic aneurysm
- Mesenteric ischemia
- Crohn disease
14. A 23-year-old woman presents to the ED with RLQ pain for the last 1 to 2 The pain is associated with nausea, vomiting, diarrhea, anorexia, and a fever of 100.9°F. She also reports dysuria. The patient returned 1 month ago from a trip to Mexico. She is sexually active with one partner but does not use contraception. She denies vaginal bleeding or discharge. Her last menstrual period was approximately 1 month ago. She has a his- tory of pyelonephritis. Based on the principles of emergency medicine, what are the three priority considerations in the diagnosis of this patient?
- Perihepatitis, gastroenteritis, cystitis
- Ectopic pregnancy, appendicitis, pyelonephritis
- Pelvic inflammatory disease (PID), gastroenteritis, cystitis
- Ectopic pregnancy, PID, menstrual cramps
- Gastroenteritis, amebic dysentery, menstrual cramps
15. A 24-year-old woman presents to the ED after being sexually She is a college student with no past medical history. Her BP is 130/75 mm Hg, HR is 91 beats per minute, temperature is 98.6°F, and RR is 16 breaths per minute. On physical examination you observe vaginal trauma and scat- tered bruising and abrasions. Which of the following medications should be offered to the patient in this scenario?
- Ceftriaxone, azithromycin, metronidazole, antiretrovirals, emergency contraception
- Ceftriaxone, tetanus, metronidazole, antiretrovirals, emergency contraception
- Ceftriaxone, azithromycin, tetanus, metronidazole, emergency contraception
- Ceftriaxone, azithromycin, tetanus, antiretrovirals, emergency contraception
- Ceftriaxone, azithromycin, tetanus, metronidazole, antiretrovirals, emergency contraception
16. A 22-year-old woman is brought to the ED by ambulance complain- ing of sudden onset of severe abdominal pain for 1 The pain is in the RLQ and is not associated with nausea, vomiting, fever, or diarrhea. On the pelvic examination you palpate a tender right adnexal mass. The patient’s last menstrual period was 6 weeks ago. Her BP is 95/65 mm Hg, HR is 124 beats per minute, temperature is 99.8°F, and RR is 20 breaths per minute. Which of the following are the most appropriate next steps in management?
- Provide her oxygen via face mask and administer morphine sulfate.
- Administer morphine sulfate, order an abdominal CT with contrast, and call an emergent surgery consult.
- Send the patient’s urine for analysis and order an abdominal CT.
- Bolus 2 L NS, order a type and crossmatch and b-hCG, and call gynecology for possible surgery.
- Provide oxygen via face mask, give morphine sulfate, and order a transvaginal ultrasound.
17. A 21-year-old woman presents to the ED complaining of diarrhea, abdom- inal cramps, fever, anorexia, and weight loss for 3 Her BP is 127/75 mm Hg, HR is 91 beats per minute, and temperature is 100.8°F. Her abdomen is soft and nontender without rebound or guarding. WBC is 9200/mL, b-hCG is negative, urinalysis is unremarkable, and stool is guaiac positive. She tells you that she has had this similar presentation four times over the past 2 months. Which of the following extraintestinal manifestations is associ- ated with Crohn disease but not ulcerative colitis?
- Ankylosing spondylitis
- Erythema nodosum
- Thromboembolic disease
18. A 23-year-old woman presents to the ED complaining of pain with She has no other complaints. Her symptoms started 3 weeks ago. During this time, she has been to the clinic twice, with negative urine cultures each time. Her condition has not improved with antibiotic ther- apy with sulfonamides or quinolones. Physical examination is normal. Wet mount showed epithelial cells. Which of the following organisms is most likely responsible for the patient’s symptoms?
- Staphylococcus aureus
- Herpes simplex virus
- Trichomonas vaginalis
- Escherichia coli
- Chlamydia trachomatis
19. A 43-year-old man presents to the ED complaining of progressively worsening abdominal pain over the past 2 The pain is constant and radiates to his back. He also describes nausea and vomiting and states he usually drinks six pack of beer daily, but has not had a drink for 2 days. His BP is 144/75 mm Hg, HR is 101 beats per minute, temperature is 99.8°F, and RR is 14 breaths per minute. He is lying on his side with his knees flexed. Examination shows voluntary guarding and tenderness to palpation of his epigastrium. Laboratory results reveal WBC 10,500/mL, hematocrit 51%, platelets 225/mL, and lipase 620 IU. An abdominal radio- graph reveals a nonspecific bowel gas pattern. There is no free air under the diaphragm. Which of the following is the most appropriate next step in management?
- Observe in the ED.
- Send home with antibiotic therapy.
- Admit to the hospital for endoscopy.
- Admit to the hospital for exploratory laparotomy.
- Admit to the hospital for medical management and supportive care.