1/ #MedTwitter, we have a new edition of the “Clinical Reasoning Corner” coming this week, which means it’s time for some more clinical reasoning practice!
Follow along and let us know how you’re thinking about the case!
Today’s chief complaint is fever & abdominal pain.
Follow along and let us know how you’re thinking about the case!
Today’s chief complaint is fever & abdominal pain.
2/ You’re called to admit a 52F w/ cirrhosis 2/2 Hepatitis C who is p/w 3 wks of progressive abdominal distension, and 2 days of abdominal pain & fevers.
She has a fever to 38.6C, scleral icterus, a diffusely tender abdomen, and a positive fluid wave.
She has a fever to 38.6C, scleral icterus, a diffusely tender abdomen, and a positive fluid wave.
3/ You and your colleague wonder whether or not she has ascites and recall a number of physical exam findings associated with it.
What clinical reasoning tool can you use to determine how each exam finding impacts the probability of ascites?
What clinical reasoning tool can you use to determine how each exam finding impacts the probability of ascites?
4/ ANS: Likelihood ratio. Likelihood ratios help us determine how a diagnostic test changes the probability of a disease. We can calculate LRs using the following equation.
5/ In this case, the positive fluid wave is the exam finding that increases the probability of ascites the most with an LR of 5.
By how much does the LR of 5 alter the probability of our patient having ascites?
By how much does the LR of 5 alter the probability of our patient having ascites?
6/ ANS: Increases by 30%. An LR of 5 increases the probability of a disease by ~30%. Check out this amazing graphic from Dr. Steven McGee’s book, Evidence-Based Physical Diagnosis.
It breaks down LRs into a simple, easy to remember framework.
It breaks down LRs into a simple, easy to remember framework.
7/ A bedside ultrasound demonstrates significant peritoneal fluid. Now that we have confirmed the presence of ascites, which question(s) do we need to answer?
8/ ANS: Both A&B. As you might recall from the episode on ascites, these are the two important questions to ask whenever you encounter a patient with ascites.
Here’s a quick refresher on one approach to ascites.
Here’s a quick refresher on one approach to ascites.
9/ Ascitic fluid studies are notable for an albumin of 1.4 g/dL (serum 3.6), a total protein of 0.7 g/dl, a total WBC count is 830 cells/mm3 with 290 neutrophils/mm3.
Is there portal HTN?
Is there portal HTN?
10/ ANS: Yes. The SAAG in this case is 2.2, which, given that it is greater than 1.1, is consistent with portal HTN.
How do the WBC & neutrophil counts help you determine whether or not the ascitic fluid is infected?
How do the WBC & neutrophil counts help you determine whether or not the ascitic fluid is infected?
11/ Would you start antibiotics?
For these answers & more pearls, check the blog tomorrow for a new post in the “Clinical Reasoning Corner”
In the meantime, review @jackpenner’s first post here: bit.ly/31t7Xmw
Thank you for reasoning with us!
For these answers & more pearls, check the blog tomorrow for a new post in the “Clinical Reasoning Corner”
In the meantime, review @jackpenner’s first post here: bit.ly/31t7Xmw
Thank you for reasoning with us!
