82.An undomiciled 41-year-old man walks into the ED complaining of
abdominal pain, nausea, and vomiting. He tells you that he has been drink-
ing beer continuously over the previous 18 hours. On examination, his
vitals are BP 150/75 mm Hg, HR 104 beats per minute, RR 16 breaths per
minute, oxygen saturation 97% on room air, temperature of 99.1°F rectally,
and finger stick glucose 81 mg/dL. The patient is alert and oriented, his
pupils anicteric. You notice gynecomastia and spider angiomata. His
abdomen is soft but tender in the RUQ. Laboratory tests reveal an AST of
212 U/L, ALT 170 U/L, alkaline phosphatase of 98 U/L, total bilirubin of
1.9 mg/dL, international normalized ratio (INR) of 1.3, WBC 12,000/μL.
Urinalysis shows 1+ protein. Chest x-ray is unremarkable. Which of the
following is the most appropriate next step in management?
a. Place a nasogastric tube in the patient’s stomach to remove any remaining
ethanol
b. Order a HIDA scan to evaluate for acute cholecystitis
c. Administer hepatitis B immune globulin
d. Send viral hepatitis titers
e. Supportive care by correcting any fluid and electrolyte imbalances
83.A 48-year-old man with a past medical history of hepatitis C and cir-
rhosis presents to the ED complaining of acute onset abdominal pain and
chills. His BP is 118/75 mm Hg, HR is 105 beats per minute, RR is 16 breaths
per minute, temperature is 101.2°F rectally, and oxygen saturation is 97% on
room air. His abdomen is distended, and diffusely tender. You decide to per-
form a paracentesis and retrieve 1 L of cloudy fluid. Laboratory analysis of
the fluid shows a neutrophil count of 550 cells/mm^3. Which of the following
is the most appropriate choice of treatment?
a. Metronidazole
b. Vancomycin
c. Sulfamethoxazole/trimethoprim (SMX/TMP)
d. Neomycin and lactulose
e. Cefotaxime
Abdominal and Pelvic Pain 81