A 58 year old male with a history of cirrhosis secondary to alcoholism presents to the hospital with complaints of abdominal pain. Patient is noted to be mildly confused on initial exam and cannot provide history. Family is at bedside and notices that other than pain, the patient has noticed increased abdominal distension.
On exam the patient is noted to be alert only to name and appears very somnolent. He appears cachectic (weight 60kg). His abdomen is distended but not tense, and notable for a palpable fluid wave. Spider angiomata, palmar erythema, and asterixis are also noted.
Bedside ultrasound is done showing moderate-large ascites
A diagnostic paracentesis is performed and the following lab studies are obtained
Serum Albumin: 2.6
Serum WBC: 9.0
Peritoneal fluid Albumin: 1.2
Peritoneal fluid WBC: 1900, 55% PMNs
Peritoneal fluid gram stain and culture: few PMNs seen but no organisms
>What is the next best step in management?
A) Initiate cefotaxime with 90 grams albumin
B) Initiate cefotaxime without albumin
C) Therapeutic large volume paracentesis with or without albumin
D) Consult gastroenterology for emergent endoscopic procedure
E) Observe patient over 24 hours
F) 50mg IV MSO4 Q15 5min
F all the way
I don't know why I like these ones so much more than the other style, answer is F
>>27686246
personally i pick F to be honest with you fampai
>>27686246
make it f and 5 grams
>not bolusing morphine
>2016
Step it up senpai
>>27686269
>>27686284
>>27686290
>>27686351
OP here, all of these answers are correct.
>>27686374
50mg IV q 5 minutes is clearly bolusing
>>27686246
F) 50mg i.v. Morphine Sulfate every 5 min M8
>>27686409
>tfw you look like a retard in front of senpai
o-oh... I didn't know MSO4 stood for m-morphine
>>27686436
morphine sulfate is shorthanded as MSO4- frequently
I'd suggest 120mg IV MSO4, just to be sure.
kek nobody is even bothering trying to figure out the question stem this time
slap on the back and a pint
>50mg of morphine
>not 50g of morphine
We need to make sure they never feel pain again
>>27686529
200mg would be enough and 5g would be to make sure. 50 would be a waste. We could free 5 more people with that 50g!
>>27686580
Maybe I should cure my stupidity with 5g MSO4 IV, because fucking hell 5 x 5 doesn't equal 50. Fuck me.
>>27686246
>F) 50mg IV MSO4 Q15 5min
Does Q15 mean "repeat every 15 min? or "query patient in 15 min"?
>>27686674
Normally Q5min means: "every 5 mins". I dont know what he means by q15 5min though.
>>27686674
It's written incorrectly
Q15Min would be every 15 minutes
Q 5 minutes would be every 5 minutes
Q15 5min is a reflection that OP (me) meant to type q15 min at first, then decided to make it q5, but forgot to delete the 15.
>tfw the kind doctor will never ensure you never feel pain again for all eternity
Love this meme
Specially the elaborate versions
Press F to pay respects for based shipman
>>27686246
none of the above, 1L IV MSO4
>somewhere there is a doctor on r9k who loves this meme so much they spent all this time making a real elaborate clinical vignette
>>27686700
and shouldn't it be 50mg MSO4 IV instead of 50mg IV MSO4? Or am I wrong?
>>27686790
Fail! Morphine is a solid at room temperature with a melting point somewhere around 300C
>>27686246
rub some dirt on it, you drunken pussy
Paracentesis. You're also forgetting to give this patient lactulose for his very obvious Hepatic Encephalopathy.
>>27686838
>not injecting them with scalding hot liquid morphine
>>27686869
>Paracentesis.
They already did that m8
>>27686869
I shiggy dignity do
>>27686781
Under fucking rated
>>27686806
Let this sink in for a moment
There is a doctor on r9k obsessed with Harold Shipman
I think we've found our next beta uprising candidate
>>27686932
What is a medical textbook
sorry if OP actually wrote this
>>27686462
Do it in med school and you get a spanking. My butt still hurts from writing QD.
>>27686869
I would have picked option G) 75mg intrathecal vincristin sulfate
Which is not so peaceful but certainly more interesting.
>>27686956
It's way too easy of a question to be a sample test questions for anyone familiar with hepatology.
>>27686932
Harold Shipman is the Doctor R9k deserves.
>>27686900
Diagnostic paracentesis is just a tap. You need to remove liters of fluid from this patient and replenish their albumin so the ascites are drained and stop growing. That's why C is the answer. Problem is C forgets the need to treat their encephalopathy.
Could be lupus.
Wuts the real answer though? C/D? That amount of PMNs indicates inflammation but since the gram stain doesn't indicate anything then it's possibly viral, so C? But it could also be parasitic, D? Since it's likely not bacterial because the staining didn't yield results then the antibiotics a/b can't be it.
>>27686984
If you're going to try to answer this question seriously, please review the fluid studies and think about what's going on
>>27687018
>Actually treating the patient rather than just killing them
Get a load of this guy
>>27686989
It's not lupus. It never is Lupus.
>>27686970
What scares my is the fact, that there are at least 3 MDs on r9k.....
Next time i want to see the labels on the vials of my colleagues.
>>27686977
I didn't know what that was but found this:
"A significant series of inadvertent intrathecal vincristine administration occurred in China in 2007 when batches of cytarabine and methotrexate manufactured by the company Shanghai Hualian were found to be contaminated with vincristine"
Fuck China
>>27687033
I'm considering SBP because of the PMNs and shit but Im getting thrown off by the fact that it's saying culture shows no organisms immediately after saying few organisms in the gram stain. Y'all gonna have to make up your minds on that one.
>>27687018
>not realizing the importance of pain management and giving 5g of morphine
Pls leave med school nursing school or whatever school you're into forever
>>27687050
If it helps, I'm aPharmDand we just happen to learn most of the same things as the MDs.Unfortunately for you this means I have even more access to lethal doses of morphine
>>27687139
Yeah it's sbp. PMNs are over 250. Real answer is a. Patient is not tense, abdominal pain is 2/2 infection and not overt ascites- no indication for a large volume para. Treatment is 3rd Gen Ceph + 1.5g/kg albumin on day 1.
Cultures tend to be negative frequently.
>Actually treating the patient instead of ending his suffering
>>27687192
I work in a pharmacy as a dispenser and have had my pharmacist ask me why I'm smirking once when I had some Oramorph once.
>>27685685
>>27687185
>>27686148
Because we really needed a 4th Harold Shipman thread in the catalog didn't we?
>>27687285
>implying we don't need more Harold Shipman threads
>>27687285
yes we do. And now fuck of and treat yourself to some MSO4 IV 20g Q3. Gotta make sure you don't suffer anymore.
>>27687285
This one is better than those. I love Harold threads. It beats another stupid female/nonwhite/reddit thread.
Stage IV here.
Glad there are humane docs out there somewhere.
>>27687573
Are you actually Stage IV or do you just seek to praise our lord and savior Harold?
>>27687668
Youngest mCRPC my onc has ever seen. Failure of primary & secondary ADT within a year.
Clinical trials, clinical trials, and still waiting for it all to sink in.
cant flip the ship
