06-13-2008, 05:02 PM
A 58-year-old woman with cirrhosis is evaluated because of a 1-week history of diffuse abdominal discomfort, feverishness, and night sweats. The patient is taking furosemide and spironolactone. She denies alcohol consumption.
On physical examination, the patient appears unwell, with a temperature of 37.5 °C (99.5 °F), pulse rate of 90/min and regular, and blood pressure of 110/80 mm Hg. There is no jaundice, but mild asterixis is present. The abdomen is soft, with tenderness to palpation in all quadrants. Ascites is present. The liver edge cannot be palpated, but a spleen tip is present just below the left costal margin. Bowel sounds are diminished.
Laboratory studies include a hemoglobin of 11.5 g/dL, leukocyte count of 8500/ml, and serum albumin of 2.6 g/dL.
Diagnostic paracentesis yields ascitic fluid with a neutrophil count of 750/mL and a negative Gram™s stain for bacteria. Cultures are pending.
Which of the following would be the most reasonable next step?
( A ) Continued observation
( B ) Administer lactulose
( C ) Perform abdominal ultrasonography
( D ) Increase diuretic doses
( E ) Prescribe antibiotics
On physical examination, the patient appears unwell, with a temperature of 37.5 °C (99.5 °F), pulse rate of 90/min and regular, and blood pressure of 110/80 mm Hg. There is no jaundice, but mild asterixis is present. The abdomen is soft, with tenderness to palpation in all quadrants. Ascites is present. The liver edge cannot be palpated, but a spleen tip is present just below the left costal margin. Bowel sounds are diminished.
Laboratory studies include a hemoglobin of 11.5 g/dL, leukocyte count of 8500/ml, and serum albumin of 2.6 g/dL.
Diagnostic paracentesis yields ascitic fluid with a neutrophil count of 750/mL and a negative Gram™s stain for bacteria. Cultures are pending.
Which of the following would be the most reasonable next step?
( A ) Continued observation
( B ) Administer lactulose
( C ) Perform abdominal ultrasonography
( D ) Increase diuretic doses
( E ) Prescribe antibiotics