Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 45-year-old man is admitted to the hospital for a 2-day history of fever and abdominal pain. His medical history is notable ...
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 45-year-old man is admitted to the hospital for a 2-day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. His medications are furosemide, spironolactone, nadolol, lactulose, zinc, vitamin A, and vitamin D.
On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 100/50 mm Hg, pulse rate is 84/min, and respiration rate is 20/min. BMI is 28. Abdominal examination discloses distention consistent with ascites. The abdomen is nontender to palpation.
Laboratory studies
Hemoglobin
10 g/dL (100 g/L)
Leukocyte count
3500/µL (3.5 × 109/L)
Platelet count
70,000/µL (70 × 109/L)
INR
1.5 (normal range, 0.8-1.2)
Albumin
2.5 g/dL (25 g/L)
Alkaline phosphatase
220 units/L
Alanine aminotransferase
30 units/L
Aspartate aminotransferase
40 units/L
Total bilirubin
4 mg/dL (68.4 µmol/L)
Creatinine
1.8 mg/dL (159 µmol/L)
Urinalysis
Normal
Abdominal ultrasound discloses cirrhosis, splenomegaly, and ascites. The portal and hepatic veins are patent, and there is no hydronephrosis. Diagnostic paracentesis discloses a cell count of 2000/µL with 20% neutrophils, a total protein level of 1 g/dL (10 g/L), and an albumin level of 0.7 g/dL (7 g/L), consistent with spontaneous bacterial peritonitis.
Which of the following is the most appropriate treatment?
A: Cefotaxime
B: Cefotaxime and albumin
C: Furosemide and spironolactone
D: Large-volume paracentesis
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