100.A 60-year-old man is brought to the ED complaining of generalized
crampy abdominal pain that occurs in waves. He has been vomiting inter-
mittently over the last 6 hours. His BP is 150/75 mm Hg, HR is 90 beats per
minute, temperature is 99.8°F, and his RR is 16 breaths per minute. On
abdominal examination you notice an old midline scar the length of his
abdomen that he states was from surgery after a gunshot wound as a teenager.
The abdomen is distended with hyperactive bowel sounds and mild tender-
ness without rebound. An abdominal plain film confirms your diagnosis.
Which of the following is the most appropriate next step in management?
a. Begin fluid resuscitation, bowel decompression with a nasogastric tube, and
request a surgical consult.
b. Begin fluid resuscitation, administer broad-spectrum antibiotics, and admit the
patient to the medical service.
c. Begin fluid resuscitation, give the patient stool softener, and administer a rectal
enema.
d. Begin fluid resuscitation, administer broad-spectrum antibiotics, and observe
the patient for 24 hours.
e. Order an abdominal ultrasound, administer antiemetics, and provide pain
relief.
101.A 73-year-old man who is a 1-pack-per-day smoker and has a medical
history of hypertension and peripheral vascular disease presents to the ED
complaining of mid-abdominal and right flank pain. He states that he had
this same pain 1 week ago and that it got so bad that he passed out. His BP
is 125/75 mm Hg, HR is 85 beats per minute, temperature is 98.7°F, and
his RR is 17 breaths per minute. Physical examination reveals a bruit over
his abdominal aorta and a pulsatile abdominal mass. Which of the follow-
ing is the most appropriate initial test to evaluate this patient?
a. Angiography
b. Ultrasound
c. MRI
d. Plain radiograph
e. D-dimer
Abdominal and Pelvic Pain 93