USMLE Forum Archives - USMLE Step 2 CK - Emergency Med Q
Emergency Med Q
Sarahhh - 12-28-07 00:52
A 31-yr-old woman smashes her car against a bridge abutment. She sustains multiple
injuries including upper and lower extremity fractures. She is awake and alert and
reports that she was not wearing a seatbelt and distinctly remembers hitting her
abdomen against the steering wheel. Blood pressure is 135/75 and her pulse is 88.
Physical examination shows that she has a rigid tender abdomen with guarding and
rebound in all four quadrants and there is no bowel sounds. Which of the following is the
most appropriate next step in evaluating potential intra-abdominal injuries.
A. Continued clinical observation.
B. CT-scan of the abdomen.
C. Sonogram of the abdomen.
D. Diagnostic peritoneal lavage.
E. Exploratory laparotomy.
Sarahhh - 12-28-07 00:52
A 31-yr-old woman smashes her car against a bridge abutment. She sustains multiple
injuries including upper and lower extremity fractures. She is awake and alert and
reports that she was not wearing a seatbelt and distinctly remembers hitting her
abdomen against the steering wheel. Blood pressure is 135/75 and her pulse is 88.
Physical examination shows that she has a rigid tender abdomen with guarding and
rebound in all four quadrants and there is no bowel sounds. Which of the following is the
most appropriate next step in evaluating potential intra-abdominal injuries.
A. Continued clinical observation.
B. CT-scan of the abdomen.
C. Sonogram of the abdomen.
D. Diagnostic peritoneal lavage.
E. Exploratory laparotomy.
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#2
Re: Emergency Med Q TheOne - 12-28-07 17:18 Although Abd CT is now considered as a "must-to-do" as it has superior hemorrhage detection than U/S; Abd U/S is quick, easy and less expensive; I will start with it.
#3
Re: Emergency Med Q InSitu - 12-28-07 18:20 
posted by HIV on 12-28-07 12:26
it's E
it's E
Explore only if in distress and the pt above has normal blood pressure and pulse. I would start with CT. I know US looks good but i feel better with CT :)
#5
Re: Emergency Med Q InSitu - 12-28-07 18:28 posted by TheOne on 12-28-07 18:26
This question is good cause it's contraversial.
This question is good cause it's contraversial.
I know...what sucks about it is you must know what USMLE want you to answer.
#8
Re: Emergency Med Q yarub14 - 12-29-07 11:20 posted by Sarahhh on 12-28-07 00:52
A 31-yr-old woman smashes her car against a bridge abutment. She sustains multiple
injuries including upper and lower extremity fractures. She is awake and alert and
reports that she was not wearing a seatbelt and distinctly remembers hitting her
abdomen against the steering wheel. Blood pressure is 135/75 and her pulse is 88.
Physical examination shows that she has a rigid tender abdomen with guarding and
rebound in all four quadrants and there is no bowel sounds. Which of the following is the
most appropriate next step in evaluating potential intra-abdominal injuries.
A. Continued clinical observation.
B. CT-scan of the abdomen.
C. Sonogram of the abdomen.
D. Diagnostic peritoneal lavage.
E. Exploratory laparotomy.
A 31-yr-old woman smashes her car against a bridge abutment. She sustains multiple
injuries including upper and lower extremity fractures. She is awake and alert and
reports that she was not wearing a seatbelt and distinctly remembers hitting her
abdomen against the steering wheel. Blood pressure is 135/75 and her pulse is 88.
Physical examination shows that she has a rigid tender abdomen with guarding and
rebound in all four quadrants and there is no bowel sounds. Which of the following is the
most appropriate next step in evaluating potential intra-abdominal injuries.
A. Continued clinical observation.
B. CT-scan of the abdomen.
C. Sonogram of the abdomen.
D. Diagnostic peritoneal lavage.
E. Exploratory laparotomy.
I think its CT of Abdomen (B).
I agree with the earlier post that the pt is stable and i dont suspect any hemorrhage to do an US (C) or the DPL (D) which would detect a bleed best. Clinical Obs (A) is too passive. And Ex Lap (E) is too aggressive cause pt is stable.
Thats my opinion, if some1 have a definite answer, please let us know to learn it. thanks everyone..
#9
Re: Emergency Med Q
Sarahhh - 12-29-07 19:35 The correct answer is E.
The presence of an "acute abdomen," which this woman has, is
an indication for exploratory surgery and prompt repair of the injuries (probably
affecting hollow viscera) that have produced the signs of peritoneal irritation.
Continued clinical observation (choice A) would be irresponsible when it is clinically
obvious that she already has an acute abdomen. What would one observe for?
Development of septic shock? Death?
CT scan (choice B) is ideal when the issue is potential intraabdominal bleeding in a
hemodynamically stabl e patient who can be safely sent to the radiology department. CT
scan might even be a good idea if the picture of acute abdomen were equivocal. But it is
not needed here.
Diagnostic peritoneal lavage (choice D) or sonogram done in the emergency department
(choice C) are our options when we suspect intraabdominal bleeding and the patient is
too unstable to be sent anywhere. As pointed out above, however, when an acute
abdomen has clearly developed, it is time to operate.
#10
Re: Emergency Med Q InSitu - 12-29-07 19:50 OMG ru serious. The patient does not seem unstable to exp lap. :) to HIV
#11
Re: Emergency Med Q TheOne - 12-29-07 19:59 Ok, I just remembered having a similar question from usmleworld and the answer was CT :) sounds more reasonable...
#12
Re: Emergency Med Q Sarahhh - 12-29-07 22:18 opps .. my bad.. i wrote the vitals wrong.. this patient was unstable. and hence the answer was E.. well at least it caused a discussion:D
#14
Re: Emergency Med Q Sarahhh - 12-29-07 23:22 haha.. naa im not that smart.. i couldnt copy it so i typed it:P and yes im not perfect.. :D so sorry about the mistake folks..
#20
Re: Emergency Med Q 8401glacieres - 01-08-08 09:40 As the patient is stable he can be shifted for an CT scan of abdomen. Considering it's high sensitivity abd specificity it is better than a USG scan of abdomen.
Diagnostic peritonial lavage is indicated for most of on table complications and in patients who r unstable and have multisystem injuries where examination is unreliable.
#21
Re: Emergency Med Q radhamesramos - 01-29-08 13:39 we could do a FAST on her first and if inconclusive...CT Scan
#22
Re: Emergency Med Q zoah2005 - 02-06-08 14:30 D is the answer ,diagnostic peritoneal lavage is gold standard for diagnosing intra abdominal hemorrhage ct scan is not as sensitive as dpl
#23
Re: Emergency Med Q radhamesramos - 02-12-08 18:50 Fast first, and if inconclussive, DPL that is the action to do
#24
Re: Emergency Med Q iqbalbahar - 02-14-08 23:09 This pat. might be in paralytic ileus due to iritation peritonium due to some demage inside.As the patient is concious and the vitals are stable after ressuscitation we can do a CT scan to know the exact sites of injury.Moreever CT is higly sensitive and specific than USG.after doing a CT we can go for laparotomy and waste little time inside and close the abdomen without confusion.
#26
Re: Emergency Med Q ammulufy - 06-29-10 20:42 The history n features r consistent wid traumatic perforation leading to peritonitis.....hence to be taken for immediate exploratory laparotomy.....hence I go wid E.
#27
Re: Emergency Med Q bingousmle - 06-30-10 16:48 the patient has guarding and rebound in all the four quadrants hence the treatment should not be delayed and the patient should be taken for an emergency laparatomy
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