During morning rounds, a physician is urgently called to evaluate a hospitalized patient w… — USMLE Step 2 CK

During morning rounds, a physician is urgently called to evaluate a hospitalized patient whose condition has suddenly deteriorated. The patient is a seventy-two-year-old retired teacher who was admitted twenty-four hours ago for an adhesive small bowel obstruction. Her initial management included nothing by mouth, intravenous crystalloid fluids, and nasogastric decompression. Currently, the patient is lethargic and moaning in pain. Vital signs indicate a temperature of $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), a pulse of $128/\text{min}$ , and a blood pressure of $86/48 \text{ mm Hg}$ . Compared to her admission examination, her abdomen is now exquisitely tender to light palpation, demonstrating rigid abdominal wall musculature and absent bowel sounds. Recent laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $6.1 \text{ mmol/L}$ . Which of the following is the most appropriate next step in the management of this patient?

A
Continue current nasogastric decompression and reassess in twelve hours
B
Request an urgent computed tomography scan of the abdomen and pelvis
C
Initiate an intravenous sodium bicarbonate infusion
Transfer to the operating suite for abdominal explorationCevap
E
Administer a therapeutic water-soluble contrast enema

Cevap

Transfer to the operating suite for abdominal exploration

The correct answer is to proceed with surgical exploration. This patient initially presented with an uncomplicated small bowel obstruction, but has now developed classic signs of strangulation and bowel ischemia. These signs include systemic toxicity (fever, marked tachycardia, hypotension), localized or generalized peritonitis (exquisite tenderness, rigid abdominal musculature), and metabolic derangements (elevated serum lactate). When a mechanical obstruction is complicated by ischemia or perforation, nonoperative management has failed. Emergent surgical exploration is required to resect the necrotic segment of bowel, relieve the obstruction, and prevent progressive sepsis.

Adım Adım Çözüm

Evaluate the clinical progression of the patient's bowel obstruction based on vital signs and physical examination.

The patient has developed new-onset fever, tachycardia, hypotension, and a rigid abdomen (peritonitis).

Identifying systemic toxicity and peritonitis is critical to differentiating an uncomplicated obstruction from a complicated (strangulated) obstruction.

Interpret the laboratory findings in the context of the clinical picture.

The patient has marked leukocytosis and elevated serum lactate (

6.1 \text{ mmol/L}

Lactic acidosis in the setting of a mechanical bowel obstruction strongly suggests bowel wall ischemia or necrosis.

Determine the definitive management strategy based on the diagnosis of a complicated/strangulated small bowel obstruction.

The patient must be taken immediately for surgical exploration.

Conservative measures fail once the bowel is ischemic; emergent operative intervention is mandated to resect necrotic tissue, clear the obstruction, and control sepsis.

Anahtar Kavram

Patients with a small bowel obstruction who develop signs of strangulation (fever, hemodynamic instability, peritonitis, leukocytosis, or lactic acidosis) require immediate surgical exploration.

Tahmini Süre:1m 15s

Soru

Cevap

Adım Adım Çözüm

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