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Mock oral exams › Emergency laparotomy in a hemodialysis patient in septic shock
Full access · Session 2: short stem · 13 questions · 35 min

Emergency laparotomy in a hemodialysis patient in septic shock

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A 61-year-old woman, 162 cm and 70 kg, with end-stage renal disease from diabetes, needs an emergency laparotomy for a perforated duodenal ulcer with generalized peritonitis. She dialyzes Monday, Wednesday and Friday through a left forearm arteriovenous fistula and missed today's Wednesday session because of pain. She makes little urine. She has hypertension and stable coronary disease.

Medications: insulin glargine, metoprolol, amlodipine, sevelamer, aspirin 81 mg.

Allergies: none known.

  • Vitals: T 38.9 °C, BP 76/40 after a 500 mL saline bolus, HR 118, RR 26, SpO2 93% on 4 L nasal cannula
  • Na 134, K 6.4, Cl 98, HCO3 14 mEq/L; glucose 228 mg/dL; albumin 3.0 g/dL
  • Arterial gas: pH 7.21, PaCO2 30 mmHg
  • Lactate 5.1 mmol/L; hemoglobin 9.0 g/dL; platelets 138,000; INR 1.3
  • ECG: sinus tachycardia, peaked T waves, QRS 98 ms
  • Access: one 20-gauge IV in the right hand