A 22-year-old white male who underwent a laparotomy two weeks ago for a perforated appendix, develops a swinging fever, dry cough, and pain in his right shoulder-tip. His temperature is 38.9 C (102 F), blood pressure is 120/76 mmHg, pulse is 110/min, and respirations are 20/min. Examination shows tenderness over the 8th to 11th rib. Abdominal and rectal examinations are within normal limits. The WBC count is 14,000/micro-L, with 6% bands. Which of the following is the best diagnostic test for this patient?

Question

A 22-year-old white male who underwent a laparotomy two weeks ago for a perforated appendix, develops a swinging fever, dry cough, and pain in his right shoulder-tip.  His temperature is 38.9 C (102 F), blood pressure is 120/76 mmHg, pulse is 110/min, and respirations are 20/min.  Examination shows tenderness over the 8th to 11th rib.  Abdominal and rectal examinations are within normal limits.  The WBC count is 14,000/micro-L, with 6% bands.  Which of the following is the best diagnostic test for this patient?

Quizplus · Accepted Answer

Explanation: The above patient is most likely suffering from a right subphrenic abscess, which typically develops 14-21 days after abdominal surgery. Clues to this diagnosis are a history of abdominal surgery, swinging fever, and leukocytosis. Cough and shoulder-tip pain may be the presenting symptoms. Of all the mentioned choices, abdominal ultrasound is the best diagnostic test. It has an accuracy of greater than 90%, and has good specificity when correlated with clinical findings. (Choice C)Abdominal x-ray findings (e.g., ileus, air-fluid levels, gas outside the lumen, or mottled soft tissue) may suggest the need for further evaluations, but are not diagnostic of a subphrenic abscess. (Choice B) Chest x-ray may show nonspecific findings (e.g., pleural effusion, atelectasis, basal infiltrates, or elevated hemidiaphragm) which are not diagnostic of a subphrenic abscess. (Choice D) Liver biopsy is not the appropriate choice. Educational Objective: Abdominal ultrasound is the best diagnostic test for a suspected subphrenic or other abdominal abscess.

A 22-Year-Old White Male Who Underwent a Laparotomy Two Weeks