erosion of one or more vertebral bodies may be seen. Atherosclerosis,
age > 60, smoking, and family history are all important predisposing fac-
tors for the development of AAA.
(b)Hyperparathyroidism may be seen in patients with recurring renal
calculi.(c)Ethanol abuse can cause pancreatitis. (d)Prostate cancer can
metastasize to the vertebral column causing blastic lesions of the spine.
(e)Hernias are the second most common cause of bowel obstruction pre-
ceded by adhesions.
119.The answer is d.(Rosen, pp 2416-2418.)You should be concerned
about a ruptured ectopic pregnancy in this patient. She missed her last men-
strual period, has severe pain in the lower abdomen, and is hypotensive. This
is a life-threatening condition that needs to be managed aggressively. The
patient requires fluid resuscitation with 2-L NS. If her BP does not respond
to the bolus, then blood should be administered. The patient will most likely
be taken to the OR for a salpingectomy/oophorectomy. Risk factors for an
ectopic pregnancy include history of pelvic inflammatory disease, prior
ectopic pregnancy, pelvic surgery, and intrauterine device (IUD) use.
(a)This will treat the pain but not its etiology. The patient is hypotensive
and this needs to be addressed. (b)This is a plan for acute appendicitis, which
is lower on the differential for this presentation than ectopic pregnancy.
(c)This is a plan if you are suspecting a renal calculus, which would present
with flank pain and microhematuria. (e)If the patient was stable then a
pelvic ultrasound might be helpful in diagnosing an ectopic pregnancy.
120.The answer is d.(Rosen, pp 1266-1268.)Murphy signis named
after the Chicago surgeon, John B. Murphy. The patient is asked to take a
deep breath while the examiner applies pressure over the area of the gall-
bladder. If the gallbladder is inflamed,the descending diaphragm forces
it against the examiner’s fingertips, causing pain and often a sudden pause
to inspiration.A sonographic Murphy sign elicits the same response with
an ultrasound probe over the gallbladder.
(a)Grey-Turner sign is ecchymotic skin in the flank area that indicates
retroperitoneal blood. It is commonly associated with hemorrhagic pancre-
atitis.(b)Kernig sign may be seen in patients with meningitis; patients can-
not extend the leg at the knee when the thigh is flexed because of stiffness
in the hamstrings. (c)McMurray sign is present when manipulation of the
tibia with the leg flexed produces pain and a pronounced click when the
meniscus has been injured. If the click occurs when the foot is rotated
126 Emergency Medicine