View source for WBR0914

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|MainCategory=Inpatient Facilities, Emergency Room
|MainCategory=Inpatient Facilities, Emergency Room
|SubCategory=Gastrointestinal
|Prompt=A 68 year old Caucasian woman comes to ER with complaints of left lower abdominal pain, fever, nausea and vomiting.  She denies passing blood in her stool.  She is a known hypertensive and hypercholesterolemia patient for the past 20 years who is on regular treatment.  She also has the complaint of chronic constipation for the past 7 years.  On physical examination, tenderness is elicited over the left lower quadrant without any guarding and rigidity.  Vitals are recorded as blood pressure 130/80 mmHg, pulse rate 92/minute, respiratory rate 18/ minute and temperature 38 C.  A complete blood count reveled leukocytosis of 18 x 109/L.  An abdominal CT revealed a sigmoid diverticulitis<BR>
<BR>
[[File:Sigmoid diverticulitis.jpg| LEFT| 200PX]]
<BR>
The next best step in management of this patient is
|Explanation=Uncomplicated [[diverticulitis]] patients with any one of the following<BR>
<BR>  
1.	Elderly<BR>  
2.	Immunocompromised<BR>  
3.	Fever with leukocytosis<BR> 
4.	Vomiting<BR> 
5.	Several comorbidities<BR>
<BR>   
should be admitted in the hospital for an in patient care that includes conservative management like nil oral, intravenous fluids, analgesics and anti emetics along with intravenous [[ciprofloxacin]] and [[metronidazole]] as broad spectrum antibiotic coverage.  Other multi drug regimens are metronidazole with [[ceftriaxone]] or metronidazole with [[aztreonam]].  Some effective monotherapies include [[piperacillin/tazobactam]], [[ampicillin/sulbactam]], [[Ticarcillin|ticarcillin/clavulanic acid]], [[imipenem]], or [[meropenem]].  On clinical improvement, intravenous antibiotics are converted to oral.  The treatment regimen should be administered for 7 to 10 days.

'''Educational Objective:'''
Uncomplicated diverticulitis patients with any one of the following<BR> 
<BR> 
1.	Elderly<BR>  
2.	Immunocompromised<BR>  
3.	Fever with leukocytosis<BR> 
4.	Vomiting<BR> 
5.	Several comorbidities<BR> 
<BR>  
should be admitted in the hospital for an in patient care that would include conservative management like nil oral, intravenous fluids, analgesics and anti emetics along with intravenous mono therapy or multidrug therapy of antibiotics, most commonly ciprofloxacin with metronidazole to give an anaerobic as well as aerobic coverage.


|AnswerA=Outpatient management with oral fluids until clinical improvement and oral ciprofloxacin with oral metronidazole for 7 to 10 days

|AnswerAExp='''Incorrect'''-Outpatient management with oral fluids until clinical improvement and oral ciprofloxacin with oral metronidazole for 7 to 10 days are for uncomplicated diverticulitis patients without the above features.
|AnswerB=Outpatient management with only oral fluids until clinical improvement
|AnswerBExp='''Incorrect'''-Outpatient management for uncomplicated diverticulitis patients with oral fluids until clinical improvement should also include oral antibiotics to control the infection. 
|AnswerC=Admission for emergent surgical exploration
|AnswerCExp='''Incorrect'''-Surgical exploration is recommended for patients with perforation with [[peritonitis]], ruptured [[abscess]], uncontrolled [[sepsis]], [[fistula]] formation, abdominal or pelvic abscess, [[intestinal obstruction]], failing medical therapy even after 3 days, and inability to rule out carcinoma.
|AnswerD=Admission for in-patient conservative management along with intravenous ciprofloxacin and metronidazole
|AnswerDExp='''Correct'''-Since the patient is elderly and presenting with vomiting, fever with leukocytosis and co-morbidities, she should be admitted in the hospital for an in patient care that would include conservative management like nil oral, intravenous fluids, analgesics and anti emetics along with intravenous mono therapy or multidrug therapy of antibiotics, most commonly ciprofloxacin with metronidazole to give an anaerobic as well as aerobic coverage.
|AnswerE=Admission for further evaluation with colonoscopy
|AnswerEExp='''Incorrect'''-[[Colonoscopy]] is advisable only for [[diverticulosis]] and not for diverticulitis because of the risk of perforation.
|RightAnswer=D
|WBRKeyword=Diverticulitis, Uncomplicated diverticulitis
|Approved=Yes
}}