USMLE Forum Archives - USMLE Step 2 CK - surgery
surgery
HIV - 12-31-07 12:35
1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step?
A ) X-ray films of the abdomen
B ) Comparison of abdominal fluid amylase with serum amylase activity
C ) Gram's stain of abdominal fluid
D ) Ultrasonography of the abdomen
E ) CT scan of the abdomen and pelvis
HIV - 12-31-07 12:35
1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step?
A ) X-ray films of the abdomen
B ) Comparison of abdominal fluid amylase with serum amylase activity
C ) Gram's stain of abdominal fluid
D ) Ultrasonography of the abdomen
E ) CT scan of the abdomen and pelvis
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#2
Re: surgery 8401glacieres - 01-13-08 00:35 C----------Gram stain of the ascitic fluid. however he yeild is positive only in 10% of cases.
According to the stem patient is having SBP & most common cause is Ecoli/Klebsiella Pneumonia.
Diagnosis is made by acsitic fluid examination and not gram stain.
Ascitic fluid examination for neutrophils > 250 and low protein.
SBP is the most common complication after SBP, and is diagnosed by a combination of clinical findings with ascitic fluid examination, however this should not prevent from starting broad spectrum antibiotics.
#3
Re: surgery laparotomy - 01-14-08 09:34 The order of management is
1. Plain film of the abdomen (x ray) to look for free air to rule out a perforation. You also need other lab results like LFTs to see if there is any suspicion for spontanous bacterial peritonitis which is common in hepatic failure patients
Ofcourse meanwhile you should start on antibiotics (Augmentin 1.2g IV tds + Metronidazole 500mg IV + Gentamycin 5mg/kg body weight) and antipyretics (paracetamol 1g IV). But first before the antibiotics take a blood culture.
2. If this does not yeild any results then a CT
3. After the CT you will pretty much be able to decide if you want to do a laparotomy (or laparoscopy)
4. If the CT is not informative (normal) then you can consider getting some ascitic fluid and checking it for neutrophils and getting a culture of that also to rule out spontaneous bacterial peritonitis. Or you could simply just continue conservative managent.
#5
Re: surgery babbu5508 - 07-07-10 21:34 C ) Gram's stain of abdominal fluid...it looks like a picture of peritonitis...may be due to peritoneal dialysis which may be the etiology
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