fever may develop. You should suspect appendicitis in any patient with
RLQ pain. Approximately 90% of patients have a WBC > 10,000/mm^3
although, the WBC can be normal in appendicitis. Urinalysis can help dif-
ferentiate urinary tract disease from acute appendicitis, although a mild
pyuria may be seen in appendicitis if the appendix is irritating the ureter.
Abdominal CT with IV and oral or rectal contrastis reported to have a
sensitivity of up to 100% and specificity of 95%. CT findings of appendici-
tis include an enlarged appendix (> 6 mm), pericecal inflammation, and
the presence of an appendicolith.
(a)Dilated loops of bowel are suggestive of bowel obstruction. (b)Many
patients who ultimately are diagnosed with appendicitis initially believed
they had food poisoning. If there is a low clinical suspicion for appendici-
tis and gastritis is more likely, than administering an antacid and observa-
tion is reasonable. However, any change in clinical examination should be
attributed to a more significant process. (c)Abdominal ultrasound is com-
monly used initially in pregnant women and children with suspected
appendicitis. Its sensitivity and specificity approaches 90%, but there may
be inadequate studies as a result of body habitus or with a retrocecal
appendix.(e)It would be inappropriate to discharge this patient home
without first evaluating for appendicitis.
86.The answer is d.(Rosen, pp 1265-1267.)The patient’s clinical picture
is consistent with biliary colicbecause of the passage of small stones from
the gallbladder through the cystic duct into the common bile duct. The
term colic is a misnomer in that these patients usually have a steady pain
rather than an intermittent pain. Pain is present in the RUQ and often is
referred to the base of the scapula. Laboratory results are commonly normal.
Ultrasound reveals stones in the gallbladder without other pathologies.
Patients can usually be sent home with pain medications and are instructed
to avoid fatty foods.
Cholangitis(a)usually presents with the triad of RUQ pain, jaundice,
and fever. Urolithiasis (b)can mimic biliary colic; however the presence of
stones in the patient’s gallbladder makes biliary colic more likely. Cholecys-
titis(c)is inflammation of the gallbladder, which can usually be seen on
ultrasound as a thickened gallbladder wall, distention, and pericholecystic
fluid. Peptic ulcer disease (e)usually presents with burning epigastric pain.
87.The answer is c.(Rosen, pp 1272-1279.)The patient’s clinical picture is
consistent with acute pancreatitis,an inflammation and self-destruction of
110 Emergency Medicine