Examkin

Soru

Zorluk: KolayPreoperative and Postoperative Care

A 71-year-old man is urgently assessed on the surgical ward due to sudden clinical deterioration. He is currently on postoperative day 5 following a small bowel resection for a benign stricture. For the last two days, he has experienced progressive abdominal distension, nausea, and failure to pass flatus. Over the past hour, his abdominal pain has become severe and constant. His temperature is 38.8°C (101.8°F), blood pressure is 84/50 mmHg, and pulse is 124/min. Abdominal examination reveals severe diffuse tenderness, board-like rigidity, and involuntary guarding. Bowel sounds are absent. Laboratory results are significant for a leukocyte count of 21,000/mm321,000/mm^3 and a serum lactate of 4.5 mmol/L4.5 \text{ mmol/L}. Which of the following is the most appropriate next step in management?

  1. A
    Placement of a nasogastric tube and serial abdominal examinations
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. Immediate exploratory laparotomyCevap
  4. D
    Intravenous antibiotic administration and intensive care observation
  5. E
    Diagnostic bedside paracentesis

Cevap

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient presents with a classic acute abdomen (characterized by board-like rigidity and involuntary guarding) combined with hemodynamic instability (hypotension, tachycardia), fever, significant leukocytosis, and lactic acidosis. In the setting of recent abdominal surgery and preceding symptoms of bowel obstruction, this clinical picture strongly suggests bowel ischemia, necrosis, or perforation (a strangulated obstruction). The standard of care for a hemodynamically unstable patient with an acute peritonitic abdomen is immediate surgical exploration to establish the definitive diagnosis and provide critical source control.

Adım Adım Çözüm

1
Identify the primary clinical syndrome from the patient's history.
The patient developed progressive distension, nausea, and obstipation on postoperative day 5, consistent with a postoperative small bowel obstruction or severe ileus.
Establishing the baseline complication helps contextualize the sudden deterioration.
2
Evaluate the patient's sudden clinical deterioration and vital signs.
The patient now exhibits fever, severe hypotension (shock), tachycardia, board-like abdominal rigidity, leukocytosis, and elevated serum lactate.
These findings distinguish an uncomplicated obstruction from a life-threatening surgical emergency.
3
Determine the appropriate management pathway for this specific presentation.
The presence of peritonitis (rigidity, guarding) combined with hemodynamic instability dictates immediate surgical exploration rather than conservative measures or further imaging.
Ischemic or perforated bowel requires immediate operative source control to prevent death.

Anahtar Kavram

Patients presenting with an acute abdomen (e.g., peritonitis, board-like rigidity) accompanied by hemodynamic instability require immediate exploratory laparotomy, bypassing further diagnostic imaging or conservative trials.
Bu soruyu puanla

Konular

Preoperative and Postoperative Care

Bu konudan daha fazla soru