80.The answer is d.(Rosen, pp 1176-1185.)The classic triadof a
ruptured abdominal aortic aneurysm (AAA)ispain, hypotension,and
apulsatile 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 unstablepatient with a diag-
nosed 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 sus-
pected of a rupturedAAA.(c)An abdominal radiograph can aid in the diag-
nosis 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.
81.The answer is c.(Rosen, pp 1283-1287.)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.
Hernias (d)are the second most common cause of obstruction. Trav-
eling to Mexico (a)may give you diarrhea and abdominal pain from enteri-
tis. 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.
82.The answer is e.(Rosen, pp 1256-1258.)The patient’s clinical presen-
tation 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.
108 Emergency Medicine