Question of the Week # 460

460)

A 65-year-old woman with a previous medical history of diabetes and rheumatoid arthritis underdoes an exploratory laparotomy for perforated sigmoid diverticulitis. Her postoperative stay is prolonged because of pneumonia, but is extubated on the fifth postoperative day and the next day discharged from the ICU to the floor. You are called by the nurse to check her wound as she noticed a new serous discharge. Her temperature is 37.0 C (98.6 F), pulse 100 beats/min, blood pressure 140/80 mm Hg, and blood glucose by finger stick 240 mg/dl. Abdomen is soft and non-tender. There is no induration, erythema, or crepitus of the wound. Copious amounts of serous brownish liquid are expressed from the wound on gentle pressure. Fluid is expressed spontaneously on coughing from both upper and lower parts of the wound. Which of the following is the most appropriate next step?
A. Start the patient on an insulin drip
B. Stop anticoagulation with subcutaneous heparin
C. Order dry dressings to be continued
D. Prescribe a 1-week course of antibiotics
E. Schedule the patient for wound exploration in the operating room

13 Responses

  1. E

  2. C

  3. E

    • E

  4. C, it is just serous fluid. there is no need for exploration cause there is no erythema, crepitus, fever.

  5. C is the answer.
    No fever or other signs of infection
    just the fluid from the gut

  6. E

  7. This patient definitely has a wound dehisence. But she is a diabetic with poor blood sugar control. 240!!! Uncontrolled diabetes can prevent wound healing. So her sugar needs control with insulin drip. Plus we need to give the patient wet dressing to promote wound healing not dry dressing. So I think answer is A.

    • although sugar is uncontrolled. discharge from the wound so i think continue course of antibiotics.d is the answer

  8. d

  9. E

  10. ELDERLY WOMEN HX OF DM AND CHRONIC INFLAMMATORY CONDITION LIKE RA THERE IS POOR HEALING FIRST STEP IS TO CONTROL HER BLOOD SUGAR SEROUS DISCHARGE IS QUITE NORMAL FINDING FROM WOUNDS REDNESS PUSSY DISCHARGE SEPARATION OF MARGIN OR HERNIATION INDICATES DEHISENCE

  11. we need the correct answer, too many answers, infection is r/o surely? with a long standing history of diabetes which is poorly controlled, poor wound healing and her previous chest infection are more likely. she will need an insulin drip as her blood sugar us poorly controlled, but what is the NEXT best step, probably new dressing and then the insulin drip.

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