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Octreotide, ceftriaxone, and metronidazole
12%
1/8
Octreotide, pantoprazole, piperacillin-tazobactam, and vancomycin
38%
3/8
Pantoprazole, metronidazole, and clindamycin
Pantoprazole, piperacillin-tazobactam, and vancomycin
Piperacillin-tazobactam and vancomycin
0%
0/8
Select Answer to see Preferred Response
This patient is presenting with sudden-onset abdominal pain with free air under the diaphragm suggesting a diagnosis of a perforated viscus. In addition to fluid resuscitation, the patient should receive a proton pump inhibitor (PPI) and IV antibiotics (pantoprazole, piperacillin-tazobactam, and vancomycin) prior to surgical repair. Perforation is a known complication of peptic ulcer disease (PUD). Patients will complain of significant abdominal pain and may present with fever, hypotension, tachycardia, and signs of peritonitis (abdominal rigidity, rebound tenderness, and hypoactive bowel sounds). An upright chest radiograph is often the first diagnostic step as free air can be visualized under the diaphragm; however, if air is not seen but clinical suspicion is high, further evaluation should be performed (which may include a CT in a stable patient or an exploratory laparotomy). Patients should immediately go to the operating room when there is a diagnosis of perforation in addition to receiving broad-spectrum antibiotics (such as vancomycin and piperacillin-tazobactam) and a proton pump inhibitor. Figure A is a radiograph demonstrating free air under the diaphragm suggesting a diagnosis of a perforated viscus. Incorrect Answers: Answer 1: Octreotide, ceftriaxone, and metronidazole would not be appropriate in a perforated viscus. Octreotide is not needed for a perforated ulcer but could be indicated for variceal bleeding. Ceftriaxone and metronidazole are not broad enough coverage for a perforated viscus. Answer 2: Octreotide, pantoprazole, piperacillin-tazobactam, and vancomycin is incorrect because octreotide is not indicated in a perforated peptic ulcer. Answer 3: Pantoprazole, metronidazole, and clindamycin is incorrect as there is not broad enough coverage for a perforated viscus and seems to have redundant coverage of anaerobes. Answer 5: Piperacillin-tazobactam and vancomycin is incorrect as a PPI is generally given in addition to broad-spectrum antibiotics for a perforated viscus. Bullet Summary: A perforated viscus should be managed with a PPI, broad-spectrum antibiotics, and emergency surgery.
4.1
(8)
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