109.The answer is a.(Rosen, pp 11415-11422.)Anobstructing stone
with an overlying infectionis an impending urologic emergency.Bacteria
in an obstructed collecting system can cause abscess formation, renal destruc-
tion, and severe systemic toxicity. The patient requires admission for IV antibi-
otics and removal and drainage of the stone. In addition to obstruction with
infection, other indications for admission include persistent pain, persistent
nausea and vomiting, urinary extravasation, and hypercalcemic crisis.
(b)Observation is not recommended. Stones smaller than 4 mm pass
90% of the time, stones 4 to 6 mm pass 50% of the time, and stones larger
than 6 mm pass 10% of the time. The patient requires IV antibiotics and
removal of the stone. (c, d,ande)The patient should not be discharged;
rather, admission is required for an infected obstructing stone. Although it
is important to keep the patient well hydrated, no evidence supports the
notion that IV hydration increases likelihood of stone passage.
110.The answer is d.(Tintinalli, pp 1878-1883.)CT scanning has become
an integral part of the ED evaluation of a patient. It is useful to differentiate
abdominal pathologies when the history and physical examination are non-
specific, or in confirming a diagnosis suspected by the clinical presentation.
Contrast materials for CT examinations in the ED are usually administered
via oral and IV routes, which improves visualization of abdominal organs.
A patient must be relatively stable to undergo a CT scan.The patient
with abdominal pain and a BP of 70/50 mm Hg is not hemodynamically
stable. His clinical presentation is consistent with a ruptured abdominal aortic
aneurysm.This is a surgical emergency and should be treated in the OR.
Obtaining a CT scan first will delay definitive treatment and worsen the
patient’s hemorrhagic shock and ultimately decrease his chance of survival.
(a)This patient sustained blunt trauma and does not show evidence of
an active bleed on the FAST examination. With stable vital signs, a CT scan
is safe. (b)This patient may have appendicitis and requires a CT scan. If she
wasβ-hCG positive, you would first perform a pelvic ultrasound to evalu-
ate for an ectopic pregnancy. (c)Pancreatitis is high on the differential; a
CT scan will help to evaluate his abdominal pain. (e)This patient most
likely has a kidney stone, which is seen on abdominal CT scan.
111.The answer is c.(Rosen, pp 1283-1287.)The clinical scenario is
highly suspicious for a strangulated loop of bowelincarcerated in a
femoral hernia.If the contents of a hernia can be returned to their natural
cavity by manual reduction, the hernia is termed reducible; if they cannot,
Abdominal and Pelvic Pain Answers 121