395.A 4-year-old uncircumcised boy is brought to the ED by his caretaker
for an 8-hour history of swelling and redness of the penis. The caretaker
states that she retracted the foreskin over the penis to clean it and could not
move it back afterward. The patient’s vital signs are within normal limits.
On examination, the patient is crying and becomes irritable whenever you
try to examine the genital area. The glans is edematous and erythematous.
The testicular examination shows bilateral descended testicles with a nor-
mal cremasteric reflex. Which of the following is the most appropriate next
step in management?
a. Manual reduction of the foreskin over the glans
b. Dorsal slit incision or circumcision
c. Topical lidocaine
d. Catheterization to prevent obstruction and urinary retention
e. Topical steroids to reduce the swelling
396.A 10-week-old girl is brought to the ED after 5 hours of abdominal
distension and green stained vomiting. The patient is a previously well
infant with an uncomplicated antenatal course and normal vaginal delivery.
However, she spent an extra day in the neonatal intensive care unit (NICU)
when born because of “water on the lungs.” On the day of presentation, the
patient is unable to hold any fluids down without vomiting. Her vital signs
reveal HR of 185 beats per minute, RR of 65 breaths per minute, and tem-
perature of 100.8°F. Abdominal examination reveals a diffusely tender
abdomen that is hypertympanic. Which of the following is the definitive
study of choice?
a. Upper GI series
b. Abdominal ultrasound
c. Findings on physical examination
d. CBC, electrolytes, and urine analysis
e. Serum lactate
416 Emergency Medicine