105.The answer is b.(Tintinalli, pp 697-699.)Pelvic inflammatory
disease(PID)comprises a spectrum of infections of the female upper repro-
ductivetract. Although N gonorrhoeaeandC trachomatisare thought to
cause the majority of infections, new evidence points to greater rates of
polymicrobial infections. Most cases of PID are thought to start with a sex-
ually transmitted disease of the lower genital tract and ascend to the upper
tract. Women typically present with lower abdominal pain and may have
vaginal discharge, vaginal bleeding, dysuria, and fever. The examination
usually reveals lower abdominal tendernessandcervical motion ten-
dernessoradnexal tenderness.Many patients are treated as outpatients
with antibiotics. Considerations for admission include those women who
are pregnant, failed outpatient therapy, are toxic appearing, have evidence
for a tubo-ovarian abscess, or a surgical emergency cannot be ruled out.
Long-term outcomes are improved if antibiotics are begun immediately.
(a)The onset of appendicitis is more insidious than what is presented
in this case. The initial symptoms are usually nausea or loss of appetite.
Pain typically begins in the periumbilical area and migrates to the RLQ.
Fever is usually not significant unless the appendix ruptures. (c)Culdo-
centesis is used to retrieve fluid in the cul-de-sac. The findings are limited
and not specific to PID. (d)Laparoscopy is not indicated in an individual
with cervicitis. It is useful to diagnose and manage ovarian torsion and
other gynecologic pathology. (e)There is no role for a plain film in this
patient. It would be useful if you suspected a bowel obstruction or free air.
106.The answer is b.(Tintinalli, pp 524-526.)The clinical scenario and
radiograph are consistent with SBO.Patients usually present with diffuse,
crampy abdominal pain thatis often episodic in nature. Typically, the
patient reports no recent bowel movements or flatus passage. The most com-
mon causes of SBO are adhesions and hernias.All patients with suspected
SBO should have flat and upright abdominal radiographs performed. Flat-
plate abdominal films can show distended loops of small bowel and the
upright film can show multiple air-fluid levels in a stepladder appearance.
(a)Constipation is a diagnosis of exclusion, although fecal impaction
is a common problem in debilitated elderly patients and may present with
symptoms of colonic obstruction. (c)Cholelithiasis typically presents with
RUQ pain and fever. Ultrasound is typically used to make the diagnosis of
cholecystitis.(d)The most common causes of large bowel obstruction
include neoplasm, diverticulitis, and sigmoid volvulus. The large bowel
contains folds called haustra that do not cross the entire bowel width.
Abdominal and Pelvic Pain Answers 119