surgery - drhmalavia

[ArchivalUser]

A young man is shot with a .45 caliber revolver, point blank in the lower abdomen, just above
the pubis. The entrance wound is at the midline, and there is no exit wound. X-ray films show
the bullet embedded in the sacral promontory, to the right of the midline. Digital rectal
examination and proctoscopic examination are unremarkable, but he has gross hematuria. He
is hemodynamically stable. Which of the following is the most appropriate next step in
management?
A. CT scan of the abdomen
B. Intravenous pyelogram
C. Retrograde cystogram
D. Diagnostic peritoneal lavage
E. Exploratory laparotomy

[ArchivalUser]

CC

[ArchivalUser]

A is the answer...what you say malaviya

[ArchivalUser]

cc

[ArchivalUser]

ee will be ultimately needed

[ArchivalUser]

ccc

[ArchivalUser]

ee

[ArchivalUser]

aaaaaaaa?

[ArchivalUser]

The correct answer is E. He has an obvious indication for exploratory laparotomy: a
gunshot wound to the abdomen. He also has evidence of injury to the urinary bladder,
but that will be dealt with at the same time that other intraabdominal injuries are found
and repaired.
CT scan (choice A) would not change the surgical approach and the surgical indication.
CT scan is called for in cases of blunt trauma to diagnose intraabdominal bleeding and
to identify intraabdominal injuries.
Intravenous pyelogram (choice B) would indeed show the bladder injury, as would a
retrograde cystogram (choice C). However, we already know clinically that there is a
bladder injury: we know the trajectory of the bullet and we have blood in the urine.
Diagnostic peritoneal lavage (choice D) is used to diagnose intraabdominal bleeding in
blunt trauma, when the patient is not stable enough to be taken to the CT scanner. In
many centers the diagnostic peritoneal lavage has been replaced by sonogram done in
the emergency department by the trauma team.