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Whenever the CK scenario tells you about a really sick patient with generalized abdominal tenderness plus rebound tenderness + guarding and rigidity and perhaps they mention some abnormal vital signs, fever and silent abdomen then you must think of Acute Surgical Abdomen and then your next step is invariably Laparotomy.

In practice that might not be the case as most ERs have quick access to CT scan and so they do it while the patient is prepped for the OT. But if you have two options of CT scan and laparotomy then choose laparotomy is the next step.

Exceptions:
The clinical scenario is equivocal like you don't have all the classic signs of acute abdomen mentioned above then you might think of the following:

  • Primary peritonitis - Antibiotics is the next step
  • MI - ECG, CXR, and Enzymes are the next steps
  • Lower lobe pneumonia - CXR is the next step
  • Pulmonary embolism - Spiral CT is the next step
  • Pancreatitis - Serum amylase is the next step
  • Renal stones - CT scan is the next step
 

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it's very useful thread sabio, thx but unfortunately seems that there are some exceptions,note this Q;

a 45 year old woman presents to the emergency complaining of acute abdominal pain, she has a history of peptic ulcer for several years that has been treated with h2 blocker,she denies diarrhea nausea or vomiting. she doesn't use alcohol or NSAIDS medication. the pain is constant and non radiating.on examination she is tachycardic but doesn't have fever.abdominal examination is remarkable for rigidity and rebound tenderness. rectal examination produces dark stool that's guaiac positive. which of the following is most appropriate next step?

(a) abdomlinal ct scan
(b) upright chest x-ray film
(c) upper endoscopy
(d) laparoscopic exploration
(e) exploratory laparatomy

writer believes that b is correct
 

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What was the explanation given for the answer B?
the correct answer is B
this patient most probably suffering from a perforated ulcer and has free air in peritoneum. such patients often present with a rigid abdomen and rebound tenderness. the best way to detect this is to look for free air under diaphragm,which is best achieved with an upright chest x-ray.

exploratory laparatomy (choice E) may be needed to correct the perforation, but the upright film should be obtained first to confirm the diagnosis.

although i don't agree with writer and we shouldn't waste time by obtaining x-ray, but above was exactly what was written as explanation.
 

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I agree with the question

the correct answer is B
this patient most probably suffering from a perforated ulcer and has free air in peritoneum. such patients often present with a rigid abdomen and rebound tenderness. the best way to detect this is to look for free air under diaphragm,which is best achieved with an upright chest x-ray.

exploratory laparatomy (choice E) may be needed to correct the perforation, but the upright film should be obtained first to confirm the diagnosis.

although i don't agree with writer and we shouldn't waste time by obtaining x-ray, but above was exactly what was written as explanation.
You know what. I agree with the writer. He did not give you an obvious laparatomy case and therefore you should do something before taking the patient to the OR.
 

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thank you sabio very informative post ..
but as atr88 pointed out isnt it essential to do some radiological investigations like erect x-rays in cases of perforated viscus or usg in cases of acute cholecystitis that present with acute abdomen before directly doing the laparatomy??
 

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Discussion Starter · #8 ·
thank you sabio very informative post ..
but as atr88 pointed out isnt it essential to do some radiological investigations like erect x-rays in cases of perforated viscus or usg in cases of acute cholecystitis that present with acute abdomen before directly doing the laparatomy??
Yes in clinical practice.
No in USMLE Step 2 CK.

Whenever you have an acute abdomen choose laparotomy
 

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thank you sabio very informative post ..
but as atr88 pointed out isnt it essential to do some radiological investigations like erect x-rays in cases of perforated viscus or usg in cases of acute cholecystitis that present with acute abdomen before directly doing the laparatomy??
I think you are right as I have seen such a case in UW, where 1st choice was Standing Chest Xray (where u can see air under diaphragm better than abdominal Xray) and as far as acute cholecystitis is concerned they mentioned going for Elective Cholecystectomy within 72 hrs after diagnosing it with USG (thickened gall bladder wall and pericholecystic fluid).

Might be few exceptions to the rule but in the rest as Sabio said Lap Lap and Lap.
 

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Most appropriate next step in management>>>>>>CxR (if CxR is among the choices)

Best/Definitive step in management>>>>>>Laprotomy (also if CxR is not among the choice)

Yes, patient needs URGENT Laprotomy but there is always time to do a CxR becuase:
1. It will be needed to r/o basal pneumonia
2. Needed by the anesthetist
3. Needed as a baseline to compare somthing with if/when patient develops post op Atelectasis/pneumonia/PE etc
4. Get a diagnosis prior to Lap.
5. It doesn't take much time/effort to get a portable upright CxR/decubitus AxR while waiting for the OR.

Patient is not bleeding to death, so there is no need to rush him/her to OR.

There are no hard & fast rules or formulas for any given question. The question writer know that some people go for the buzzwords etc and they lay the trap for them. Remember, They want you to have an understanding of the given scenario and arrive at the answer in a knowledgeable/logical thinking manner based on the information given in the question stem.
 

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Nicely said Novobicin!

"There are no hard & fast rules or formulas for any given question. The question writer know that some people go for the buzzwords etc and they lay the trap for them. Remember, They want you to have an understanding of the given scenario and arrive at the answer in a knowledgeable/logical thinking manner based on the information given in thequestion stem."

Exactly, every case is unique, I wouldn't choose to lap the peptice ulcer woman unless she was unstable.
 
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