is used to detect an intrauterine pregnancy. If no intrauterine pregnancy is
detected, the suspicion for an ectopic pregnancy increases. (d)An abdominal
radiograph may be obtained later in the workup, but is not currently indi-
cated.(e)Observation is not an acceptable option in any patient with undif-
ferentiated abdominal pain and vaginal bleeding. It is imperative that the
clinician rule out an ectopic pregnancy in this individual.
92.The answer is e.(Rosen, pp 1176-1185.)The patient presents with
multiple risk factors for an AAA: age > 60, male gender, hypertension,
cigarette smoking,andperipheral artery disease.Classically, AAA pre-
sents with constant abdominal pain, often localizing to the left middle or
lower quadrant with radiation to the back. Physical examination may
reveal a pulsatile abdominal mass.Patients can present unstable if the
aneurysm leaks or ruptures requiring emergent management in the OR.
Evidence of an AAA is seen on plain radiograph approximately 66% to
75% of the time. The most common findings are curvilinear calcification of
the aortic wall or a paravertebral soft tissue mass. Ultrasound and CT are
the best diagnostic tools for the stable patient.
(a)Biliary colic occurs in the RUQ and usually lasts less than 6 hours.
(b)The pain of a kidney stone is usually described as colicky in nature. Pain
typically begins in the flank and radiates to the groin. (c)Pancreatitis typi-
cally presents with mid-epigastric pain that radiates to the back and is asso-
ciated with nausea and vomiting.(d)SBO is diagnosed on radiography by
evidence of dilated loops of bowel, air-fluid levels, and thickening of the
bowel wall.
93.The answer is c.(Rosen, p 1276.)Lipase is a pancreatic enzymethat
hydrolyzes triglycerides. In the presence of pancreatic inflammation it
increases within 4 to 8 hours and peaks at 24 hours. At five times the upper
limits of normal,lipase is 60% sensitive and 100% specificfor pancreati-
tis. The diagnosis is usually made with a lipase of two times the normal limit,
thereby increasing its sensitivity.
(a)Elevations of amylase are approximately 70% specific for the diag-
nosis of pancreatitis. (b, d, and e)are all laboratory values that are used in
the prognosis for pancreatitis, not for its diagnosis.
94.The answer is a.(Rosen, pp 1423-1425.)The patient has epididymitis.
It is often difficult to distinguish epididymitis from testicular torsion and the
clinician should always rule out torsion first if the diagnosis is in doubt. It is
Abdominal and Pelvic Pain Answers 113