tommyk
05-20-2006, 04:28 AM
Hy 2220
A 60-year-old depressed man with alcoholic cirrhosis (he drank Jim Bean whisky) and stomach cancer presents with a 1-day history of diffuse abdominal pain in all 4 quadrants. He denies chills, nausea or vomiting. He never had an episode before, but has had a history of esophageal varices. His regular meds include thiamine, multivitamins, and folate. On physical examination, he is febrile and in mild distress. His abdomen is distended with a clear fluid wave. There is diffuse tenderness on abdominal palpation. Paracentesis reveals a clear fluid with 1000 leukocytes/µL, with a predominance of neutrophils (80%). Gram's stain shows no bacteria. Which of the following is the most likely diagnosis?
1-Abd ascites
2-Cholelithiasis
3-Cholecystitis
4-Liver abscess
5-Esophageal strictures
6-Mallory Weiss Tears
7-A-V malformations in the GI Tract
8-Primary peritonitis
9-Pancreatitis
ans) #8. The patient is exhibiting symptoms consistent with primary peritonitis. It can be difficult to distinguish between primary (spontaneous) peritonitis and rupture of a hollow viscus resulting in peritoneal soiling. The presence of fever and leukocytes in the ascitic fluid suggests a peritoneal infection. Cholecystitis is associated with abdominal pain in the right upper quadrant, elevated direct and indirect bilirubin, and nausea and vomiting.Do not be fooled with grammar and language, Cholecystitis IS a diagnosis, but Cholelithiasis is more of a “finding”. It is a subtle, very tricky concept that one of my attending told me about since stones can be asymtomatic. Liver abscess presents as a subacute illness without prominent peritoneal symptoms. Diagnosis is often made by abdominal imaging, such as CT or ultrasound. There is no history of drinking so rule OUT #6..Pancreatitis is characterized by severe localized (midepigastric) pain, which radiates to the back. Amylase and lipase levels may be elevated. Calcium levels may be diminished. Peptic ulcer disease is possible in this patient with a history of alcohol abuse. Patients will typically be afebrile, and ascitic fluid should not reveal leukocytosis. A complication of ulcer disease would be perforation.
A 60-year-old depressed man with alcoholic cirrhosis (he drank Jim Bean whisky) and stomach cancer presents with a 1-day history of diffuse abdominal pain in all 4 quadrants. He denies chills, nausea or vomiting. He never had an episode before, but has had a history of esophageal varices. His regular meds include thiamine, multivitamins, and folate. On physical examination, he is febrile and in mild distress. His abdomen is distended with a clear fluid wave. There is diffuse tenderness on abdominal palpation. Paracentesis reveals a clear fluid with 1000 leukocytes/µL, with a predominance of neutrophils (80%). Gram's stain shows no bacteria. Which of the following is the most likely diagnosis?
1-Abd ascites
2-Cholelithiasis
3-Cholecystitis
4-Liver abscess
5-Esophageal strictures
6-Mallory Weiss Tears
7-A-V malformations in the GI Tract
8-Primary peritonitis
9-Pancreatitis
ans) #8. The patient is exhibiting symptoms consistent with primary peritonitis. It can be difficult to distinguish between primary (spontaneous) peritonitis and rupture of a hollow viscus resulting in peritoneal soiling. The presence of fever and leukocytes in the ascitic fluid suggests a peritoneal infection. Cholecystitis is associated with abdominal pain in the right upper quadrant, elevated direct and indirect bilirubin, and nausea and vomiting.Do not be fooled with grammar and language, Cholecystitis IS a diagnosis, but Cholelithiasis is more of a “finding”. It is a subtle, very tricky concept that one of my attending told me about since stones can be asymtomatic. Liver abscess presents as a subacute illness without prominent peritoneal symptoms. Diagnosis is often made by abdominal imaging, such as CT or ultrasound. There is no history of drinking so rule OUT #6..Pancreatitis is characterized by severe localized (midepigastric) pain, which radiates to the back. Amylase and lipase levels may be elevated. Calcium levels may be diminished. Peptic ulcer disease is possible in this patient with a history of alcohol abuse. Patients will typically be afebrile, and ascitic fluid should not reveal leukocytosis. A complication of ulcer disease would be perforation.