The management is principally supportive,with correction of any fluid or
electrolyte imbalances, paying special attention to blood glucose (ethanol
can suppress gluconeogenesis) and magnesium. Thiamine may also be
deficient in chronic alcoholics.
Suctioning the patient’s stomach with a nasogastric tube (a)is not indi-
cated and should not be performed. A HIDA scan (b)is the most accurate
test for establishing the diagnosis of cholecystitis. However, before a HIDA
is performed, individuals with suspected cholecystitis should undergo ultra-
sound scanning. Unless this is a known needle stick or mucosal exposure,
hepatitis immune globulin (c)is not acutely indicated. Viral hepatitis titers
(d)can be drawn as an outpatient if suspicious for a viral infection.
83.The answer is e.(Rosen, p 1261.)Analysis of abdominal fluid and clin-
ical presentation are consistent with spontaneous bacterial peritonitis (SBP).
It is recommended to start antibiotic treatment for SBP if the neutrophil count
is greater than 250 cells/mm^3. Causative organisms include gram-negative
enterococcus such as E coliandKlebsiella,as well as Streptococcussp., and
Streptococcus pneumoniae.Therefore, the most appropriate antibiotic for treat-
ment is a third-generation cephalosporin,such as cefotaxime.
84.The answer is e.(Rosen, pp 1422-1423.) Testicular torsion is a
surgicalemergency. There are two peak periods in which torsion is likely
to occur, the first year of life and at puberty. Manual detorsioncan be
attempted in most cases while arranging for definitive care. After appropri-
ate analgesia, the anterior testicle should be twisted laterally, like opening a
book.Color Doppler ultrasoundis the best test of choice in most hospitals.
Immediate evaluation and referral to a urologist is essential.
To administer ceftriaxone and doxycycline (a)and swab his urethra
(b)is the correct management for urethritis. A urinalysis (c)should be sent on
most patients with scrotal pain but in this case the diagnosis of torsion takes
precedence. Although epididymitis (d)and torsion have similar presenta-
tions, epididymitis usually has more of a gradual onset, reaching a peak over
days. Epididymitis is the most common misdiagnosis of testicular torsion.
85.The answer is d.(Rosen, pp 1293-1297.)Appendicitis is the most
common cause of the acute surgical abdomen. It can occur at any age but
is most prevalent in the teens and twenties. It is classically described as
starting with the vague onset of dull periumbilical pain that migrates to
the RLQ.It is associated with anorexia, nausea, and vomiting. A low-grade
Abdominal and Pelvic Pain Answers 109