104.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 hour. 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 nondistended, diffusely tender,
worst in the RLQ. Pelvic examination reveals a normal sized uterus and
moderate right-sided adnexal tenderness. Laboratory results reveal WBC
10,000/μL, hematocrit 38%, and a negative urinalysis and β-hCG. Pelvic
ultrasound reveals an enlarged right ovary with decreased flow. Which of
the following is the most appropriate management for this patient?
a. Admit to the gynecology service for observation
b. Administer IV antibiotics and operate once inflammation resolves
c. Attempt manual detorsion
d. Order an abdominal CT
e. Immediate laparoscopic surgery
105.An 18-year-old woman presents to the ED complaining of acute onset
of RLQ abdominal pain. 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 examination reveals
lower abdominal tenderness bilaterally. On pelvic examination you elicit
cervical motion tenderness and note cervical exudates. Her WBC is
20,500/μL and β-hCG is negative. Which of the following is the most
appropriate next step in management?
a. Bring her to the OR for an appendectomy
b. Begin antibiotic therapy
c. Perform a culdocentesis
d. Bring her to the OR for immediate laparoscopy
e. Order an abdominal plain film
Abdominal and Pelvic Pain 95