of severe RLQ pain, then the risks (eg, radiation exposure to the fetus) and
benefits (eg, diagnosing appendicitis) of performing a CT scan must be dis-
cussed.(d)A urinalysis is part of the general workup, but is not emergently
needed.(e)Any patient with a positive pregnancy test, abdominal pain,
and vaginal bleeding needs to undergo an urgent evaluation for an ectopic
pregnancy.
103.The answer is d.(Rosen, pp 1272-1276.)The patient’s clinical picture
is consistent with acute pancreatitis.Ranson developed criteria that help
predict mortality ratesin patients with pancreatitis. The presence of more
than three criteria equals 1% mortality, while the presence of six or more cri-
teria approaches 100% mortality. Ranson criteriaat admission are age > 55,
WBC > 16,000, glucose > 200, LDH > 350, AST > 250. Within 48 hours of
admission, hematocrit fall > 10%, BUN rise > 5, serum calcium < 8, arterial
PO 2 < 60, base deficit > 4, and fluid sequestration > 6 L. The patient in the
case fulfills four of Ranson criteria and has approximately 15% mortality
risk. Note that lipase and amylase are not part of Ranson criteria despite
being relevant in the diagnosis of acute pancreatitis.
104.The answer is e.(Rosen, p 223.)The differential diagnosis in a
woman with RLQ pain is expansive and includes GI pathology, such as
appendicitis, inflammatory bowel disease, diverticulitis, and hernia. Gyneco-
logic pathology includes ectopic pregnancy, tubo-ovarian abscess, ruptured
corpus luteum cyst, and ovarian torsion. It is often difficult to initially distin-
guish between gastrointestinal (GI) and gynecologic (GYN) pathology and
which diagnostic test, abdominal CT, or a pelvic ultrasound, is warranted.
Often, the decision is based on the pelvic examination. The patient in the
question exhibits adnexal tendernessand therefore received a pelvic ultra-
sound that revealed a unilateral enlarged ovary with decreased flow,
indicative of ovarian torsion.Ovarian torsion is a gynecologic emergency
and conservative management has no place in the treatment decision of sus-
pected torsion even if pain improves in the ED. Failure to surgically correct
this entity may result in ischemia and subsequent necrosis of the involved
ovary. Therefore, the mainstay of therapy is laparoscopyorlaparotomy.
(a)Conservative management is not an option in suspected ovarian
torsion.(b)Antibiotics and delayed surgery may be acceptable for a tubo-
ovarian abscess. (c)Manual detorsion is not possible in the female patient.
It can be attempted in the male patient.(d)If pelvic ultrasound was normal
and there is suspicion for GI pathology, then abdominal CT is warranted.
118 Emergency Medicine