Gynecologic emergency procedures — MCQs

10 questions

A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?

A 20-year-old woman is brought to the emergency department 6 hours after the onset of colicky lower abdominal pain that has been progressively worsening. The pain is associated with nausea and vomiting. She has stable inflammatory bowel disease treated with 5-aminosalicylic acid. She is sexually active with her boyfriend and they use condoms inconsistently. She was diagnosed with chlamydia one year ago. Her temperature is 38.1°C (100.6°F), pulse is 94/min, respirations are 22/min, and blood pressure is 120/80 mm Hg. Examination shows right lower quadrant guarding and rebound tenderness. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 25-year-old homeless woman presents to an urgent care clinic complaining of vaginal bleeding. She also has vague lower right abdominal pain which started a few hours ago and is increasing in intensity. The medical history is significant for chronic hepatitis C infection, and she claims to take a pill for it 'every now and then.' The temperature is 36.0°C (98.6°F), the blood pressure is 110/70 mmHg, and the pulse is 80/min. The abdominal examination is positive for localized right adnexal tenderness; no rebound tenderness or guarding is noted. A transvaginal ultrasound confirms a 2.0 cm gestational sac in the right fallopian tube. What is the next appropriate step in the management of this patient?

A 23-year-old woman comes to the emergency department because of increasing abdominal pain with associated nausea and vomiting. The symptoms began suddenly after having intercourse with her partner six hours ago. There is no associated fever, diarrhea, vaginal bleeding, or discharge. Menarche was at the age of 13 years and her last menstrual period was 4 weeks ago. She uses combination contraceptive pills. She had an appendectomy at the age of 12. Her temperature is 37.5°C (99.5°F), pulse is 100/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows severe right lower quadrant tenderness with associated rebound and guarding. Pelvic examination shows scant, clear vaginal discharge and right adnexal tenderness. There is no cervical wall motion tenderness. Her hemoglobin concentration is 10.5 g/dL, leukocyte count is 9,000/mm3, and platelet count is 250,000/mm3. A urine pregnancy test is negative. Which of the following imaging findings is most likely?

A 24-year-old woman is brought to the emergency department after being assaulted. The paramedics report that the patient was found conscious and reported being kicked many times in the torso. She is alert and able to respond to questions. She denies any head trauma. She has a past medical history of endometriosis and a tubo-ovarian abscess that was removed surgically two years ago. Her only home medication is oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 82/51 mmHg, pulse is 136/min, respirations are 24/min, and SpO2 is 94%. She has superficial lacerations to the face and severe bruising over her chest and abdomen. Her lungs are clear to auscultation bilaterally and her abdomen is soft, distended, and diffusely tender to palpation. Her skin is cool and clammy. Her FAST exam reveals fluid in the perisplenic space. Which of the following is the next best step in management?

A 24-year-old woman presents to the emergency department for evaluation of lower abdominal pain. She endorses 6 hours of progressively worsening pain. She denies any significant past medical history and her physical examination is positive for non-specific, diffuse pelvic discomfort. She denies the possibility of pregnancy given her consistent use of condoms with her partner. The vital signs are: blood pressure, 111/68 mm Hg; pulse, 71/min; and respiratory rate, 15/min. She is afebrile. Which of the following is the next best step in her management?

Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?

A 27-year-old woman with a past medical history of rheumatoid arthritis and severe anemia of chronic disease presents to the emergency department for nausea, vomiting, and abdominal pain that started this morning. She has been unable to tolerate oral intake during this time. Her blood pressure is 107/58 mmHg, pulse is 127/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for left lower quadrant abdominal pain upon palpation. A urine pregnancy test is positive, and a serum beta-hCG is 1,110 mIU/mL. A transvaginal ultrasound demonstrates no free fluid and is unable to identify an intrauterine pregnancy. The patient states that she intends to have children in the future. Which of the following is the best next step in management?

A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management?

Q10

An 18-year-old woman presents to the emergency department with severe right lower quadrant discomfort and stomach pain for the past day. She has no significant past medical history. She states that she is sexually active and uses oral contraceptive pills for birth control. Her vital signs include: blood pressure 127/81 mm Hg, pulse 101/min, respiratory rate 19/min, and temperature 39.0°C (102.2°F). Abdominal examination is significant for focal tenderness and guarding in the right lower quadrant. Blood is drawn for lab tests which reveal the following: Hb% 13 gm/dL Total count (WBC) 15,400 /mm3 Differential count Neutrophils: Segmented 70% Band Form 5% Lymphocytes 20% Monocytes 5% What is the next best step in the management of this patient?

Gynecologic emergency procedures US Medical PG Practice Questions and MCQs

Question 1: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?

A. Bladder trigone
B. Uterine artery
C. Kidney
D. Ureter (Correct Answer)

Explanation: ***Ureter*** - The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim. - During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury. *Bladder trigone* - The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice. - It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament. *Uterine artery* - The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament. - While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself. *Kidney* - The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis. - They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.

Question 2: A 20-year-old woman is brought to the emergency department 6 hours after the onset of colicky lower abdominal pain that has been progressively worsening. The pain is associated with nausea and vomiting. She has stable inflammatory bowel disease treated with 5-aminosalicylic acid. She is sexually active with her boyfriend and they use condoms inconsistently. She was diagnosed with chlamydia one year ago. Her temperature is 38.1°C (100.6°F), pulse is 94/min, respirations are 22/min, and blood pressure is 120/80 mm Hg. Examination shows right lower quadrant guarding and rebound tenderness. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Urine culture
B. Erect abdominal x-ray
C. Serum β-hCG concentration (Correct Answer)
D. Transvaginal ultrasound
E. CT scan of the abdomen

Explanation: ***Serum β-hCG concentration*** - The patient is a **sexually active woman** with colicky lower abdominal pain, nausea, and vomiting, raising suspicion for an **ectopic pregnancy**. - A **serum β-hCG concentration test** is crucial to **rule out pregnancy** as a cause of her symptoms, especially given her inconsistent condom use. *Urine culture* - While a urinary tract infection (UTI) can cause lower abdominal pain, the presentation of **guarding and rebound tenderness** in the right lower quadrant is **less typical for a simple UTI** and suggests a more acute abdominal process. - Although ruling out a UTI is important, it is **not the most immediate priority** given the potential for a life-threatening ectopic pregnancy. *Erect abdominal x-ray* - An erect abdominal x-ray is primarily used to detect **free air under the diaphragm** in cases of **bowel perforation** or to identify **bowel obstruction**. - While helpful in some abdominal emergencies, it is **less sensitive for diagnosing the differential diagnoses** pertinent to this patient's presentation (e.g., appendicitis, ectopic pregnancy). *Transvaginal ultrasound* - A **transvaginal ultrasound** would be an important next step **after confirming pregnancy** to determine if it is intrauterine or ectopic. - However, performing an ultrasound **before confirming pregnancy** with β-hCG is not the most efficient initial approach for evaluating acute abdominal pain in a sexually active woman. *CT scan of the abdomen* - A CT scan of the abdomen would be highly useful for diagnosing conditions like **appendicitis** or complications of inflammatory bowel disease. - However, in a **woman of childbearing age**, a CT scan should generally be performed **after ruling out pregnancy** due to radiation exposure risks to a potential fetus.

Question 3: A 25-year-old homeless woman presents to an urgent care clinic complaining of vaginal bleeding. She also has vague lower right abdominal pain which started a few hours ago and is increasing in intensity. The medical history is significant for chronic hepatitis C infection, and she claims to take a pill for it 'every now and then.' The temperature is 36.0°C (98.6°F), the blood pressure is 110/70 mmHg, and the pulse is 80/min. The abdominal examination is positive for localized right adnexal tenderness; no rebound tenderness or guarding is noted. A transvaginal ultrasound confirms a 2.0 cm gestational sac in the right fallopian tube. What is the next appropriate step in the management of this patient?

A. Tubal ligation
B. Methotrexate
C. IV fluids, then surgery (Correct Answer)
D. Surgery
E. Pelvic CT without contrast

Explanation: ***IV fluids, then surgery*** - This patient presents with an **ectopic pregnancy** confirmed by transvaginal ultrasound, along with signs of evolving instability (increasing pain, vaginal bleeding). She is also **hemodynamically stable** at present, so **resuscitation** with intravenous fluids is indicated before surgical intervention to prevent further deterioration. - While she is hemodynamically stable, the symptoms suggest the ectopic pregnancy is **progressing or rupturing**, necessitating a definitive surgical treatment to remove the gestastional sac and prevent hemorrhage. *Tubal ligation* - **Tubal ligation** is a permanent sterilization procedure and is not indicated for the management of an acute ectopic pregnancy. - While the ectopic pregnancy is in the fallopian tube, the immediate goal is to remove the ectopic pregnancy, not to sterilize the patient. *Methotrexate* - **Methotrexate** is an option for **medically stable** patients with **small, unruptured ectopic pregnancies**, without signs of hemodynamic instability or significant pain, and who can adhere to follow-up. - This patient has increasing pain, suggesting impending rupture or active bleeding, making methotrexate less appropriate. Her history of chronic hepatitis C and potential non-adherence to medication also makes methotrexate, a hepatotoxic drug, risky. *Surgery* - **Surgery** is the definitive treatment for an ectopic pregnancy. However, in any patient presenting with pain and vaginal bleeding, even if hemodynamically stable, initial **resuscitation with IV fluids** is crucial before proceeding with surgery to ensure optimal patient outcomes and prevent hypovolemia. - Directly proceeding to surgery without initial stabilization carries a higher risk, especially given the potential for significant blood loss during surgical removal of an ectopic pregnancy. *Pelvic CT without contrast* - A **pelvic CT without contrast** is not indicated as the initial management step for a confirmed ectopic pregnancy. - The diagnosis is already confirmed by transvaginal ultrasound, and a CT scan would expose the patient to unnecessary radiation without adding critical information for acute management.

Question 4: A 23-year-old woman comes to the emergency department because of increasing abdominal pain with associated nausea and vomiting. The symptoms began suddenly after having intercourse with her partner six hours ago. There is no associated fever, diarrhea, vaginal bleeding, or discharge. Menarche was at the age of 13 years and her last menstrual period was 4 weeks ago. She uses combination contraceptive pills. She had an appendectomy at the age of 12. Her temperature is 37.5°C (99.5°F), pulse is 100/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows severe right lower quadrant tenderness with associated rebound and guarding. Pelvic examination shows scant, clear vaginal discharge and right adnexal tenderness. There is no cervical wall motion tenderness. Her hemoglobin concentration is 10.5 g/dL, leukocyte count is 9,000/mm3, and platelet count is 250,000/mm3. A urine pregnancy test is negative. Which of the following imaging findings is most likely?

A. Increased ovarian blood flow on doppler
B. Decreased ovarian blood flow on doppler (Correct Answer)
C. Complex, echogenic intrauterine mass
D. Distended fallopian tube with incomplete septations
E. Echogenic tubal ring

Explanation: ***Decreased ovarian blood flow on doppler*** - This clinical presentation, particularly the sudden onset of **unilateral abdominal pain** after intercourse, associated nausea/vomiting, and severe right lower quadrant tenderness with rebound/guarding, is highly suggestive of **ovarian torsion**. - **Ovarian torsion** *is a medical emergency in which the ovary twists on its pedicle, obstructing its blood supply. This causes rapid onset of symptoms and can lead to necrosis of the ovary if not promptly treated.* **Doppler ultrasound** *will show decreased or absent blood flow to the affected ovary, which is key to its diagnosis*. *Increased ovarian blood flow on doppler* - **Increased ovarian blood flow** would suggest an inflammatory process or a highly vascularized mass, which is less consistent with the acute, severe ischemic pain described. - *While some inflammatory conditions or ruptured cysts might present with similar pain, the sudden, severe nature following intercourse points towards a mechanical event like torsion rather than increased flow.* *Complex, echogenic intrauterine mass* - A **complex, echogenic intrauterine mass** is indicative of conditions like fibroids, polyps, or retained products of conception, typically presenting with abnormal uterine bleeding or chronic pelvic pain, not acute unilateral abdominal pain after intercourse. - *The absence of vaginal bleeding and a negative pregnancy test further rule out most intrauterine pregnancy-related issues.* *Distended fallopian tube with incomplete septations* - A **distended fallopian tube with incomplete septations** is a hallmark of **hydrosalpinx** or **pyosalpinx**, often associated with pelvic inflammatory disease (PID). - *While PID can cause adnexal tenderness, the acute onset after intercourse with guarding and rebound in the absence of fever, vaginal discharge (except scant clear), or cervical motion tenderness makes PID less likely.* *Echogenic tubal ring* - An **echogenic tubal ring** is a classic sign of an **ectopic pregnancy** within the fallopian tube. - *The patient's negative urine pregnancy test makes ectopic pregnancy extremely unlikely, despite the adnexal pain.*

Question 5: A 24-year-old woman is brought to the emergency department after being assaulted. The paramedics report that the patient was found conscious and reported being kicked many times in the torso. She is alert and able to respond to questions. She denies any head trauma. She has a past medical history of endometriosis and a tubo-ovarian abscess that was removed surgically two years ago. Her only home medication is oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 82/51 mmHg, pulse is 136/min, respirations are 24/min, and SpO2 is 94%. She has superficial lacerations to the face and severe bruising over her chest and abdomen. Her lungs are clear to auscultation bilaterally and her abdomen is soft, distended, and diffusely tender to palpation. Her skin is cool and clammy. Her FAST exam reveals fluid in the perisplenic space. Which of the following is the next best step in management?

A. Emergency laparotomy (Correct Answer)
B. Abdominal radiograph
C. Abdominal CT
D. Fluid resuscitation
E. Diagnostic peritoneal lavage

Explanation: ***Emergency laparotomy*** - The patient presents with **hemodynamic instability** (BP 82/51 mmHg, HR 136/min) and a **positive FAST exam** showing fluid in the perisplenic space, indicating intra-abdominal hemorrhage. - According to **ATLS guidelines**, a hemodynamically unstable patient with a positive FAST exam requires **immediate operative intervention** to control bleeding. This is the definitive management for ongoing hemorrhage. - While fluid resuscitation is initiated simultaneously (en route to OR), **surgical control of the bleeding source** is the priority and should not be delayed. *Fluid resuscitation* - Fluid resuscitation with IV crystalloids is essential and should be started immediately in this patient with hypovolemic shock. - However, in a patient with **uncontrolled intra-abdominal hemorrhage** (positive FAST, hemodynamic instability), fluids alone will not stop the bleeding. Continued fluid resuscitation without surgical intervention can lead to dilutional coagulopathy and worsening outcomes. - Fluid resuscitation occurs **concurrently with preparation for surgery**, not as a separate step that delays definitive management. *Diagnostic peritoneal lavage* - DPL is an invasive diagnostic procedure that has largely been replaced by FAST exam in modern trauma care. - Given that the **FAST is already positive**, DPL would provide no additional useful information and would only **delay definitive surgical management**. - In hemodynamically unstable patients with positive FAST, proceeding directly to laparotomy is indicated. *Abdominal radiograph* - Plain radiographs have **limited sensitivity** for detecting intra-abdominal bleeding or solid organ injury. - They may show free air (indicating hollow viscus perforation) but cannot assess for fluid or characterize solid organ injuries. - This would **delay necessary operative intervention** without providing actionable information. *Abdominal CT* - CT abdomen is the imaging modality of choice for **hemodynamically stable** trauma patients to characterize injuries and guide management. - For **unstable patients**, CT is **contraindicated** as it delays definitive treatment and removes the patient from a resuscitation environment where deterioration can be immediately addressed.

Question 6: A 24-year-old woman presents to the emergency department for evaluation of lower abdominal pain. She endorses 6 hours of progressively worsening pain. She denies any significant past medical history and her physical examination is positive for non-specific, diffuse pelvic discomfort. She denies the possibility of pregnancy given her consistent use of condoms with her partner. The vital signs are: blood pressure, 111/68 mm Hg; pulse, 71/min; and respiratory rate, 15/min. She is afebrile. Which of the following is the next best step in her management?

A. Surgical consultation
B. Admission and observation
C. Obtain a pelvic ultrasound
D. Serum hCG (Correct Answer)
E. Abdominal CT scan

Explanation: ***Serum hCG*** - Despite the patient's claim of consistent condom use, **pregnancy must be ruled out** in any woman of reproductive age presenting with lower abdominal pain. **Ectopic pregnancy** is a life-threatening condition that can present this way. - A **serum hCG** is more sensitive than a urine test and can detect very early pregnancies, which is crucial for prompt diagnosis and management. *Surgical consultation* - Surgical consultation would be premature without a definitive diagnosis or clear signs of an acute surgical abdomen, such as peritonitis or hemodynamic instability. - Initial diagnostic steps are necessary to identify the cause of the pain before considering surgical intervention. *Admission and observation* - While observation might be necessary, it's not the immediate next best step. Without a diagnosis, observation alone may delay critical interventions for conditions like ectopic pregnancy. - Admission for observation typically follows initial diagnostic workup when the diagnosis is uncertain but not immediately life-threatening. *Obtain a pelvic ultrasound* - A pelvic ultrasound is an important diagnostic tool for evaluating pelvic pain, but it should be performed only **after pregnancy has been ruled out** or confirmed. - If the patient is pregnant, a pelvic ultrasound would be used to assess for intrauterine or ectopic pregnancy. If she is not pregnant, the ultrasound would help identify other gynecological causes of pain. *Abdominal CT scan* - An abdominal CT scan is less specific for gynecological causes of pain and exposes the patient to **ionizing radiation**, making it a less ideal initial step compared to ruling out pregnancy. - It might be considered if the initial workup for gynecological causes is negative or if there are concerns for other intra-abdominal pathology.

Question 7: Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?

A. Suspensory ligament
B. Round ligament
C. Ovarian ligament
D. Uterosacral ligament
E. Cardinal ligament (Correct Answer)

Explanation: ***Cardinal ligament*** - The **uterine artery** and **uterine vein**, which supply the uterus, run through the **cardinal ligament** (also known as the transverse cervical ligament). - Ligation of these vessels is crucial during a hysterectomy to control bleeding from the uterus. *Suspensory ligament* - The **suspensory ligament of the ovary** contains the **ovarian artery** and vein, which primarily supply the ovaries and fallopian tubes. - While these may be ligated during a hysterectomy if the ovaries are removed, they are not the primary vessels causing uterine bleeding in postpartum hemorrhage. *Round ligament* - The **round ligament of the uterus** extends from the uterus to the labia majora and contains relatively small vessels, primarily contributing to uterine support. - Ligation of this ligament alone would not effectively control heavy uterine bleeding. *Ovarian ligament* - The **ovarian ligament** connects the ovary to the uterus and contains small vessels that mainly supply the ovary. - It does not house the major blood supply to the uterus itself. *Uterosacral ligament* - The **uterosacral ligaments** primarily provide support to the uterus by connecting it to the sacrum and contain small nerves and vessels. - Ligation of these ligaments would not control the main arterial supply to the uterus.

Question 8: A 27-year-old woman with a past medical history of rheumatoid arthritis and severe anemia of chronic disease presents to the emergency department for nausea, vomiting, and abdominal pain that started this morning. She has been unable to tolerate oral intake during this time. Her blood pressure is 107/58 mmHg, pulse is 127/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for left lower quadrant abdominal pain upon palpation. A urine pregnancy test is positive, and a serum beta-hCG is 1,110 mIU/mL. A transvaginal ultrasound demonstrates no free fluid and is unable to identify an intrauterine pregnancy. The patient states that she intends to have children in the future. Which of the following is the best next step in management?

A. Repeat beta-hCG in 2 days (Correct Answer)
B. CT scan of the abdomen
C. Methotrexate
D. Salpingostomy
E. Salpingectomy

Explanation: ***Repeat beta-hCG in 2 days*** - With a beta-hCG level of **1,110 mIU/mL** and no intrauterine pregnancy seen on ultrasound, a **repeat beta-hCG in 48 hours** is the most appropriate next step to assess the trend and differentiate between an early, viable intrauterine pregnancy, a non-viable pregnancy (miscarriage), or an ectopic pregnancy. - The patient is currently **hemodynamically stable**, which allows for expectant management and further diagnostic evaluation rather than immediate intervention. *CT scan of the abdomen* - A CT scan of the abdomen exposes the patient to **ionizing radiation**, which is generally avoided in pregnancy unless absolutely necessary. - It would not provide the specific diagnostic information needed to evaluate for an **ectopic pregnancy** as effectively as serial beta-hCG levels and repeat ultrasound. *Methotrexate* - **Methotrexate** is a potential treatment for ectopic pregnancy, but it is not the first step in diagnosis and would only be considered after a definitive diagnosis. - The patient's **hemodynamic stability** and desire for future fertility make a conservative approach involving more diagnostic steps preferable before initiating medical treatment. *Salpingostomy* - **Salpingostomy** is a surgical procedure to remove an ectopic pregnancy while preserving the fallopian tube, but it is a definitive treatment and not a diagnostic step. - It would be considered for a **confirmed ectopic pregnancy** in a stable patient who desires future fertility, but only after further diagnostic evaluation. *Salpingectomy* - **Salpingectomy**, the surgical removal of the fallopian tube, is a treatment for ectopic pregnancy, most often reserved for cases of **rupture**, significant tubal damage, or patients who do not desire future fertility from that tube. - This patient is **hemodynamically stable** and desires future fertility, making salpingectomy an inappropriate initial choice.

Question 9: A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management?

A. Admission and observation
B. Chest radiograph
C. 12 lead electrocardiogram
D. Abdominal CT scan (Correct Answer)
E. Abdominal ultrasound

Explanation: ***Abdominal CT scan*** - This patient presents with classic signs of a **perforated peptic ulcer**: sudden severe epigastric pain radiating to the shoulders (diaphragmatic irritation), fever, tachycardia, hypotension, and peritoneal signs (rigid abdomen with rebound tenderness). - While the patient shows signs of **early shock** (BP 100/60, HR 120), he is **conscious and maintaining adequate oxygenation** (SpO2 98%), making him stable enough for rapid CT imaging. - **Abdominal CT scan** is the **most sensitive and specific** test for detecting free air, identifying the location of perforation, and assessing for complications (abscess, contained perforation). - CT provides **critical surgical planning information** about the extent and location of perforation, which can guide the surgical approach. - This should be followed by **immediate surgical consultation** and preparation for emergency laparotomy. *Chest radiograph* - While an **upright chest X-ray** can detect free air under the diaphragm (pneumoperitoneum), it has **lower sensitivity** (70-80%) compared to CT scan (>95%). - In a patient who is stable enough for imaging, **CT is preferred** as it provides more information for surgical planning. - Chest X-ray would be the appropriate choice only if **CT is unavailable** or if the patient is **too unstable** to be transported to the CT scanner. *Admission and observation* - This patient has **acute peritonitis** from a likely perforated viscus, which is a **surgical emergency** requiring operative intervention. - Observation would be inappropriate and dangerous, leading to **septic shock**, **multi-organ failure**, and death. *12 lead electrocardiogram* - While epigastric pain can sometimes be cardiac in origin, the **peritoneal signs** (rigid abdomen, rebound tenderness, hypoactive bowel sounds) clearly indicate an **intra-abdominal pathology**. - The pain radiation to **both shoulders** (Kehr's sign) suggests diaphragmatic irritation from intraperitoneal air or fluid, not cardiac ischemia. *Abdominal ultrasound* - Ultrasound is useful for evaluating **solid organ injury**, **free fluid**, and conditions like **cholecystitis** or **appendicitis**. - However, it is **poor at detecting free air** due to bowel gas artifact and has limited sensitivity for perforated viscus. - It would not provide adequate information for this surgical emergency.

Question 10: An 18-year-old woman presents to the emergency department with severe right lower quadrant discomfort and stomach pain for the past day. She has no significant past medical history. She states that she is sexually active and uses oral contraceptive pills for birth control. Her vital signs include: blood pressure 127/81 mm Hg, pulse 101/min, respiratory rate 19/min, and temperature 39.0°C (102.2°F). Abdominal examination is significant for focal tenderness and guarding in the right lower quadrant. Blood is drawn for lab tests which reveal the following: Hb% 13 gm/dL Total count (WBC) 15,400 /mm3 Differential count Neutrophils: Segmented 70% Band Form 5% Lymphocytes 20% Monocytes 5% What is the next best step in the management of this patient?

A. Upper gastrointestinal series
B. Pelvic exam
C. Ultrasound of the appendix
D. Upper gastrointestinal endoscopy
E. Ultrasound of the pelvis (Correct Answer)

Explanation: ***Ultrasound of the pelvis*** - In a young woman presenting with **right lower quadrant pain, fever, leukocytosis with left shift, and peritoneal signs (guarding)**, the next best step is **pelvic ultrasound**. - This imaging modality can evaluate **both surgical and gynecological causes** of acute abdomen, including **appendicitis, ovarian torsion, tubo-ovarian abscess, ectopic pregnancy**, and **ruptured ovarian cyst**. - **Pelvic ultrasound is the first-line imaging** for RLQ pain in women of reproductive age because it avoids radiation and provides comprehensive evaluation of pelvic structures. - The clinical picture (high fever 39°C, significant leukocytosis 15,400 with left shift, guarding) suggests **acute appendicitis** as the most likely diagnosis, but gynecological emergencies must also be excluded. *Pelvic exam* - While important in evaluating gynecological causes, a **pelvic exam should not precede imaging** in a patient with peritoneal signs (guarding) and high suspicion for surgical emergency. - In the setting of acute abdomen with fever and leukocytosis, **imaging takes priority** to identify the source and guide management. - Pelvic exam would be appropriate **after imaging** if gynecological pathology is identified or if there are specific findings suggesting PID (bilateral pain, cervical discharge). - The presentation is more consistent with **appendicitis than PID**, which typically causes bilateral lower abdominal pain and cervical motion tenderness. *Upper gastrointestinal series* - An **upper GI series** uses X-rays and contrast to visualize the esophagus, stomach, and duodenum. - It is indicated for evaluating **GERD, peptic ulcer disease, or dysphagia**, which are not suggested by this patient's acute RLQ pain and fever. - This would be inappropriate for acute abdominal pain with peritoneal signs. *Upper gastrointestinal endoscopy* - This procedure directly visualizes the upper GI tract to diagnose **esophagitis, gastric ulcers, or malignancy**. - It has no role in the evaluation of acute **lower quadrant pain** with systemic inflammatory signs. - This would delay appropriate diagnosis and treatment of a surgical emergency. *Ultrasound of the appendix* - While **ultrasound can visualize the appendix**, a **pelvic ultrasound** is preferred because it provides a **comprehensive evaluation** of both the appendix and gynecological structures. - In women of reproductive age with RLQ pain, gynecological causes must be excluded, making **pelvic ultrasound more appropriate** than focusing solely on the appendix. - If pelvic ultrasound is inconclusive for appendicitis, **CT abdomen/pelvis with contrast** would be the next step.

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