thick-walled, fluid-filled spherical structure without multiple echogenic
structures casting shadows. (c)Ovarian cysts would not appear as multiple
echogenic structures casting shadows within a central cavity, but rather as
spherical, fluid-filled structures. (e)A liver abscess can be visualized on
ultrasound as a hypoechoic area in one of the lobes of the liver.
98.The answer is b.(Rosen, pp 1330-1332.)Management for complicated
acute diverticulitisinvolvesadmissionandantibiotic treatment. Treat-
ment is directed against both anaerobic and gram-negative bacteria. Intra-
abdominalabscessformation secondary to diverticulitis requires prompt
surgical consultation and should be drainedusing CT or ultrasound-guided
percutaneous draining. Abscesses less than 5 cm in diameter may be treated
with antibiotics alone.
The patient’s vital signs are stable and there is no evidence for peri-
tonitis, therefore she does not require an emergent laparotomy (a).The
patient should not be discharged from the hospital (c).Because of the risk
for bowel perforation, barium enema and colonoscopy are contraindicated
(dande);however, once the diverticulitis is controlled, the patient should
undergo one of the procedures to look for other pathology and exclude
complications, such as fistula formation.
99.The answer is e.(Rosen, p 1294.)Rovsing signis the referred tender-
ness to the RLQ when the LLQ is palpated. It is seen with acute appendicitis.
Blumberg sign (a)is the occurrence of a sharp pain when the examiner
presses his or her hand over McBurney point and then releases the hand
pressure suddenly. This sign is indicative of peritoneal inflammation. The
Psoas sign (b)is the increase of pain when the psoas muscle is stretched as
the patient extends his or her hip. The Obturator sign (c)is the elicitation of
pain as the hip is flexed and internally rotated. Raynaud sign(d)is a condition
marked by symmetrical cyanosis of the extremities with persistent, uneven,
mottled blue or red discoloration of the skin of the digits, wrists, and ankles,
along with profuse sweating and coldness of the fingers and toes.
100.The answer is a.(Rosen, pp 1283-1287.)The patient’s clinical picture
is consistent with a SBO. Fluid resuscitationis important because of the
inability of the distended bowel to absorb fluid and electrolytes at a normal
rate. Compounded with vomiting, fluid loses can lead to hypovolemia and
shock.Nasogastric suctionprovides enteral decompression by removing
accumulated gas and fluid proximal to the obstruction. A surgical consult
116 Emergency Medicine