Ivonne
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A 75 yo M complains to a physician of abdominal pain. His temperature is 37 C(98.6F), BP: 110/65, pulse: 63 and respirations: 16. The abdomen is soft, with focal tenderness in the left lower quadrant. His erythrocyte count is 4.5millon/mm3, leukocyte count is 11 000/mm3 with 60% neutrophils and 5% bands, and platelet count is 250 000. Which of the following is the most appropriate next step in diagnosis:
a.- Barium enema
b.-Colonoscopy
c.-CT of abdomen
d.-Plain film of abdomen
e.-Trial theraphy of a liquid diet
Explain your answer pz
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| brutus25
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D - AXR to r/o free air , ileus or obstruction
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| Adam
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CT
WBC is high, it could be diverticulitis.. in old patients, fever may not be present
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| Korotkoff
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I will go for B. His leukocyte count is OK. I think his RBC is low. Don't you think this patient had some chronic bleeding?
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| drshvetasm
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C: CT scan...always radiological diagnosis in acute phase...after acute episode subsides with conservative management..this one most likely will coz of normal WBC and differential...then f/u with colonoscopy to confirm diverticular disease.
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| Korotkoff
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I was thinking Colon ca.
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| bax
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c
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| drduck
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fever leucocytosis and pain.......acute appendicitis???
CT scan is the best for diagnosis....but USG is best initial choice.
4.5 million is not low its normal.....
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| drduck
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every thing seems to be normal.....it can be a case of chronic constipaton, as no other diagnosis fits perfect.
yes, LIQUID THERAPY can be benificial....can relieve constipation...
acute appendicitis not so common in this age....
what is the answer, and who said its very easy???
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| Aashi
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drduck wrote:
fever leucocytosis and pain.......acute appendicitis???
CT scan is the best for diagnosis....but USG is best initial choice.
4.5 million is not low its normal.....
Pt has LLQ pain, appendix is found MC'ly in the RLQ....
Since the q asked for NEXT STEP in the dx and NOT THE BEST step-------------------->I would go with ABDOMINAL XRAY.
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| neurom
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D - to check for free air
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| Ivonne
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Te correct answer is E ( I got this Q wrong, picked CT)
The probable diagnosis is diverticulitis. The relatively mild symptoms, normal vital signs and relatively normal laboratory values in this patient indicate that he is not very ill. this means that he can be treated first with rest, a liquid diet and antibiotics. In this setting, the response to the therapeutic trial itself serves as a confirmatory test. In most cases, the symptoms will resolve rapidly on its regimen.
CT of the abdomen is used in severe cases when the differencial diagnosis includes pelvic abscess and appendicitis.
Plain film of the abdomen is of limited utility in this setting but may show increased gas in the bowel if the diverticultitis has lowered intestinal motility.
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| Korotkoff
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oops! I was thinking erythrocyte is low. You are right it is normal.
I won't get the right answer anyway.
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| Adam
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e.-Trial theraphy of a liquid diet !!!!!!!!
But they didn't write antibiotics in the question,, I thought, we can't deal with diverticulitis just with liquids... in addition , CT is the best thing to diagnose such cases, what ever mild symptoms or severe ones.. Correct me pls if i am wrong.. tnx
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| Ivonne
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I agree with you Adam that is why i picked CT of the abdomen but i think that the most important point is before jumping to the automatic brain sinapsis(mine worked that way): diverticulitis------> CT of the abdomen is think about the steps in the management for instance the diagnosis of diverticulitis can be made in the basis of the history and physical examination and mild cases can be started as a outpatient treatment regimen.
Take a look this article(don't get me wrong i am not in defense of the question writers i am just trying to learn from the question)
http://www.emedicine.com/med/TOPIC578.HTM#section...
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| Adam
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parameter wrote: Imaging Studies: - No imaging study is needed when the diagnosis of diverticulitis is likely on clinical grounds.
- A CT scan of the abdomen is considered the optimal imaging method.
- A CT scan is useful to determine the extent of complications in patients who are severely ill.
I GOT IT Ivonne, this is new for me,,, really thanks.
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I will not say I failed 1000 times.. I will say that I discovered there are 1000 ways that can cause failure ..
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