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.
78.The answer is e.(Rosen, pp 1266-1268.)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 sus-
picion 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 cholescintigra-
phy (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.
79.The answer is c.(Rosen, pp 1414-1422.)The patient’s history of col-
icky flank pain that radiates to the groin and hematuria is consistent with a
ureteral stone. Adequateanalgesiais critical in treating a patient with a
ureteral stone. Intravenous ketorolac,an nonsteroidal anti-inflammatory
drug (NSAID), is frequently administered as a first-line analgesic, but mor-
phine 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 tor-
sion(e)should always be considered in a patient with groin pain. In this
case, a stone is more consistent with the history.
Abdominal and Pelvic Pain Answers 107