Question

An 83 year old female with dementia is brought to the physician by her granddaughter because of a change in her skin color, which has taken on a golden hue over the past few days. The patient's granddaughter also reports that she has been unable to get the patient to eat or drink for the past 24 hours, and that although the patient's urine output has decreased, her urine appeared dark brown when she changed her diaper this morning. Vital signs are temperature 39.1 C (102.4 F), pulse 105, blood pressure 77/45, respiratory rate 24, oxygen saturation 96% on room air. On physical examination, the patient is somnolent but arousable to pain. The skin is jaundiced and the sclerae are icteric. Lungs are clear to auscultation. Abdominal examination reveals decreased bowel sounds, with diffuse tenderness to palpation. There is voluntary guarding of the right upper quadrant. Which of the following is the most appropriate next step in management for this patient?

A. Abdominal CT
B. Administer 1 L bolus of 0.9% NaCl
C. Begin i.v. nafcillin
D. Urgent endoscopic retrograde pancreaticoduodenoscopy (ERCP)
E. Percutaneous transhepatic drainage tube placement

Answer 1

The most appropriate next step in managing the hypotensive and jaundiced elderly patient is to administer a 1 liter bolus of 0.9% NaCl to stabilize her cardiovascular status before proceeding with further diagnostics or treatments.

Step-by-step explanation:

The patient is an 83-year-old female with dementia presenting with jaundice, decreased urine output with dark urine, reduced oral intake, and hypotension. These symptoms suggest potential liver dysfunction and shock, possibly due to a number of causes including sepsis or hepatobiliary pathology. Considering her hemodynamic instability indicated by a low blood pressure and altered mental status, the most appropriate next step in management for this patient is to stabilize her cardiovascular status.

Therefore, the correct answer is: B. Administer 1 L bolus of 0.9% NaCl. This action is crucial as the first line of management to resuscitate and improve the patient's blood pressure, which can be critical for maintaining organ perfusion and preventing further deterioration. While other options such as an abdominal CT or ERCP might be considered later in her care for diagnostic purposes, the priority is to address the patient's immediate need for fluid resuscitation.