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Old 09-18-2012
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Default What test or procedure ?????

A 40-year-old woman presents to the urologist
for evaluation of a renal mass discovered incidentally
on CT of the abdomen. The mass was
5 cm in diameter, originating from the upper
pole of the right kidney. The center of the mass
contains an area of calcifi cation. The patient
has a distant history of acute pancreatitis secondary
to a scorpion bite and a 20-pack-year smoking
history. She does not drink alcohol. The decision
was made to proceed with surgical
removal of the mass, and a partial nephrectomy
was performed. The patient did well postoperatively,
and her Foley catheter was removed on
postoperative day 2. That evening she had substantial
output into a Jackson-Pratt drain that the
surgeons left in place. The output of the drain
has been 30 cc/hr for the past few hours, and
the fl uid is light pink to clear. The patient is examined
and states that she is not in pain. Her
temperature is 37.7°C (99.8°F), heart rate is 80/
min, and blood pressure is 110/70 mm Hg.
What test or procedure would be appropriate to
confi rm the suspected diagnosis?

(A) Exploratory laparotomy
(B) Measurement of amylase level in Jackson-
Pratt drain
(C) Measurement of creatinine level in Jackson-
Pratt drain
(D) Measurement of serum amylase level
(E) Measurement of serum hemoglobin level
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  #2  
Old 09-18-2012
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ans .........B...
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Old 09-18-2012
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Probably B.. wtf is a jackson whatever thing? lol
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Old 09-18-2012
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The correct answer is C. The fl uid in the
Jackson-Pratt drain is urine. This is secondary
to a leak in the resected kidney. A urine leak
such as this should be considered when injury
to the ureter, kidney, or bladder is possible
(i.e., iatrogenically in obstetric/gynecologic or
urologic surgery). The suspicion that fl uid contains
urine can be easily confi rmed by sending
the fl uid for a creatinine level. When this level
is higher than expected in the patient’s blood
(there is no reason to suspect an elevated serum
creatinine in this patient), the suspicion
is confi rmed. The timing also suggests that the
patient has a urine leak because the Foley catheter
has just been removed. The catheter had
been keeping the bladder empty so the urine
had a low resistance path to follow and the
Jackson-Pratt drain was relatively urine free.
Answer A is incorrect. An exploratory laparotomy
is not needed in this situation. Furthermore,
a urine leak such as this can usually be
managed expectantly. Drainage of the bladder
with a catheter may aid the healing of the iatrogenic
injury.
Answer B is incorrect. Measuring the urinary
amylase level would be useful if fl uid of pancreatic
origin was suspected. The patient does
not have pancreatitis, or more specifi cally, a
pseudocyst, making the diagnosis of pancreatic
fl uid unlikely. Also, given that the surgical procedure
was urologic in nature, a urine leak is
more likely.
Answer D is incorrect. A serum amylase test
has no role here. Serum amylase is used in diagnosing
pancreatitis. The patient has no epigastric
pain, and there is no reason to think
that an acute attack of pancreatitis would cause
an increase in drain output.
Answer E is incorrect. Serum hemoglobin
should be checked postoperatively if bleeding
is suspected. However, the fl uid is described as
clear and not grossly bloody.
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