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ADMISSION CONFERENCE August 2010

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1 ADMISSION CONFERENCE 2010 02 August 2010
ASMPH Clerkship – SURGERY ROTATION St. Martin de Porres Charity Hospital 02 August 2010

2 Admissions from August 2-August 8, 2010
# Patient ID Admitting Diagnosis Operation Done Final Diagnosis 1 RJ,23/M Ileocecal Tuberculosis, Ulcerohypertrophic type 2 JP,15/M Small Bowel Obstruction probably 2’ to Ruptured AP “E” Exploratory Laparotomy, Appendectomy 3 RM,42/M Cholelithiasis Lap Chole 4 MA,18/F Fistula in ano Fistulotomy

3 Admissions from August 2-August 8, 2010
# Patient ID Admitting Diagnosis Operation Done Final Diagnosis 5 GV,45/F Calculous Cholecystitis Lap Cholecystectomy 6 EA,63/F Acute Cholecystitis 7 NV,77/F Femoral neck fracture Garden Type IV Partial Hip replacement 8 MM,25/M Acute Appendicitis “E” Appendectomy Ruptured Appendicitis

4 General Data RJ, 23/M CC: RLQ pain

5 HPI 7 mos PTA (+) intermittent epigastric pain. Stabbing character. Aggravated by oral intake. Alleviated when eats less, passing flatus, and belching. Associated with bloating and vomiting. No radiations. 5/10 severity. -Pt sought consult with local doctor treated as dyspepsia, given meds w/c provided no relief.

6 Subjective Findings 3 mos PTA
Persistence of epigastric pain. Pt’s relatives noted gradual weight loss. Undocumented fever. Persistence of pain prompted consult with another doctor. EGD procedure was done with negative results. Esophagogastroduodenoscopy (EGD)

7 Subjective Findings 2 mos PTA
- Pain localized to RLQ area. Colicky character. Aggravated by oral intake. Associated with bloating, vomiting, bulge in RLQ, 28% wt loss, and alternating diarrhea (2-5x/day) with constipation (2-3days). Alleviated when eats less, passing flatus, belching, and massaging RLQ. No radiations. 8-9/10 severity. Esophagogastroduodenoscopy (EGD)

8 Subjective Findings 2 mos PTA
-CT scan and colonscopy was done at De Los Santos Medical Center. - CT scan revealed ileitis with mild colitis of the cecum. Associated few ileocecal regional mesenteric lymphadenopathies. Esophagogastroduodenoscopy (EGD)

9 Subjective Findings 2 mos PTA
Colonoscopy revealed inflammatory bowel disease. Biopsy revealed chronic iliocolitis with ulcer, granulation tissue, benign lymphoid aggregate and reactive epithelial change. Prednisone was given w/c afforded temporary relief.

10 Subjective Findings 1 mo PTA
Repeat colonoscopy was done, ileocecal TB was considered. Surgery was recommended due to obstructive symptoms hence admission. ADMISSION

11 Subjective Findings ROS: General: (+) Fever, weight loss, weakness
Musculo/Skin: (–) Rashes, joint pains, jaundice, muscle pains HEENT: (–) Headache, tinnitus, deafness cough, colds, enlarged LN Resp: (–) Dyspnea, hemoptysis, wheeze Cardio: (–) Palpitations, chest pains, syncope GI: (–) Inguinal lymphadenopathies Genitourinary: (–) Nocturia (–) Dysuria, hematuria Endocrine: (–) Excessive sweat, heat intolerance, cold intolerance

12 Subjective Findings Past Medical History: (+) Mumps, 13 y/o
(–) Allergies to food or medicines (+) BCG (–) TB The duration of protection after neonatal BCG vaccination is not well known but commonly believed to decline gradually to non-significant levels after 10–20 years. In Saudi Arabia, the protective efficacy of neonatal BCG vaccination against pulmonary, meningeal or disseminated TB was followed over a 20-year period and shown to be 82% in children younger than 15 years, 67% in the 15–24 age group, and 20% in persons aged 25–34 years. (WHO, Weekly epidemiological record)

13 Subjective Findings Family history:
(+) Diabetes, (+) Hypertension Social history: Smoker; 1.6 pack years, occasional alcoholic beverage drinker

14 Objective Findings Height: 165cm Weight: 42kg BMI: 15 BP: 100 / 70
Temp: 36.7°C HR: 106 RR: 22 Underweight, slight tachycardic, slight tachypnea

15 Objective Findings Gen: Alert, Coherent, Not in Resp. distress
HEENT: Anicteric sclera, pink palpebral conjunctiva, (–) CLAD, (–) TPC, Dry tongue and buccal mucosa, Flat neck veins Cardio: Adynamic precordium, Apex beat 5th LICS MCL, Normal rate, Regular rhythm, (–) Murmur Pulmo: SCE, Resonant lung fields, Clear breath sounds, (–) Crackles and wheezes

16 Objective Findings GI: Scaphoid, hypoactive bowel sounds, tympanitic, soft, (+) Direct tenderness on deep palpation of RLQ, (–) Rebound, (–) Masses organomegaly, surgical scar Extremities: Pulses full and equal, (–) edema, cyanosis, good turgor DRE: (–) skin tags, (–) perianal masses or tenderness, Good sphincter tone, (–) Pararectal tenderness or masses, Empty rectal vault, feces on tactating finger

17 Salient Features 23/M Colicky RLQ pain.
Associated with bloating, vomiting, bulge in RLQ, 28% wt loss, fever, and alternating diarrhea (2-5x/day) with constipation (2-3days). Aggravated by oral intake. Alleviated when eats less, passing flatus, belching, and massaging RLQ. No radiations. 8-9/10 severity.

18 Salient Features GI PE: Scaphoid, hypoactive bowel sounds, tympanitic, soft, (+) Direct tenderness on deep palpation of RLQ, (–) Rebound, (–) Masses organomegaly, surgical scar DRE: (–) perianal masses or tenderness, Good sphincter tone, (–) Pararectal tenderness or masses, Empty rectal vault, feces on tactating finger

19 Salient Features (–) EGD
Dx Labs: (–) EGD CT revealed ileitis and mild colitis of the cecum. Regional mesenteric lymphadenopathes. Colonscopy revealed chronic ileocolonic inflammation, T/C ileocecal TB. Biopsy of ileocecal area revealed chronic ileocolitis with ulcer, granulation tissue, benign lymphoid aggregates, reactive epithelial change. No granuloma or dysplasia.

20 Assessment Primary Impression: Ileocecal Tuberculosis, Ulcerohypertrophic type Differentials: Chronic Inflammatory Bowel Disease: Chron’s Lymphoma Colon Cancer

21 Plan Diagnostic Plan: CBC ESR PPD CXR CT abdomen AFB of biopsy
PCR of biopsy Culture of biopsy

22 Plan Anti- TB Medications (WHO Tx of TB Guidelines, 2009)
Anti-TB Drugs: Pulmonary and extrapulmonary disease should be treated with the same regimens. (Strong/High grade of Evidence) Surgery for late complications -WHO: Pulmonary and extrapulmonary disease should be treated with the same regimens (see Chapter 3>>>New patients with pulmonary TB should receive a regimen containing 6 months of rifampicin: 2HRZE/4HR >> Strong/High grade of Evidence).1 Note that some experts recommend 9–12 months of treatment for TB meningitis (2, 3) given the serious risk of disability and mortality, and 9 months of treatment for TB of bones or joints because of the difficulties of assessing treatment response (3). Unless drug resistance is suspected, adjuvant corticosteroid treatment is recommended for TB meningitis and pericarditis (1–4). In tuberculous meningitis, ethambutol should be replaced by streptomycin. -WHO: Although sometimes required for diagnosis, surgery plays little role in the treatment of extrapulmonary TB. It is reserved for management of late complications of disease such as hydrocephalus, obstructive uropathy, constrictive pericarditis and neurological involvement from Pott’s disease (spinal TB). For large, fluctuant lymph nodes that appear to be about to drain spontaneously, aspiration or incision and drainage appear beneficial (3). -Surgery as Treatment: (Chir 1997, World J. Surg. 21, 492–499, 1997) When performing a planned laparotomy in a patient in whom the diagnosis of tuberculosis has not been made or considered, it is difficult to resist resection of abnormal segments of bowel. At least it should provide a histologic diagnosis. For acute perforation or obstruction that fails to resolve, surgery is clearly essential [83]. Generally, surgery is reserved for complications of the disease. A limited right hemicolectomy, with about 5 cm margins from visibly abnormal tissue [106], may be required for an ileocecal mass and small bowel resection for strictures within a short segment—both with end-to-end anastomoses. Multiple small-bowel strictures may be treated by strictureplasty to avoid major resection [120, 121]. Recurrent adhesive obstruction may require small bowel stenting [19]. Surgery for bleeding usually requires resection, but occasionally embolization is possible. The latter has been successful for controlling severe cecal bleeding [122]. Bypass surgery for obstructing lesions, such as an ileotransverse anastomosis for an ileocecal mass, must be avoided, as a blind loop syndrome usually results together with deterioration of the patient [19].

23

24 Text here

25 Right hemi? colectomy and anastomosis

26 Return to table

27 Identifying Data JP, 15/M Date of birth: August 9, 1995
Currently resides in Bonifacio Exit, Bagong Silangan QC Date of admission: August 3, :45 am CC: Abdominal Pain and Distention

28 Subjective Findings: HPI
5 days PTA Persistent hypogastric pain Pain scale of 7/10 No radiation On and off fever Sough consult in a local health center diagnosed with UTI Given Co-Amoxiclav and Domperidone Treatment offered partial temporary relief

29 Subjective Findings: HPI
3 days PTA Hypogastric pain localized to the LLQ 7 episodes of vomiting of previously ingested food 7 episodes of diarrhea Stools described as wet and yellow

30 Subjective Findings: HPI
2 days PTA Abdominal distention noted to be relieved by vomiting Persistence and development of new symptoms led to admission in East Avenue Treated as AGE Unrecalled IV medication Placed on NPO NGT inserted

31 Subjective Findings: HPI
1 day PTA Allowed to eat Abdominal distention worsened with each meal Abdominal pain now described as diffuse accompanied by abdominal rigidity Persistence of diarrhea and vomiting ADMISSION

32 Subjective Findings: ROS
General (-) changes in weight, (-) fatigue, (-) weakness HEENT (-) headache, (-) colds, (-) enlarged lymph nodes Respiratory (-) cough, (-)dyspnea, (-) wheezing Cardiovascular (-) orthopnea, (-)palpitations, (-) chest pain Gastrointestinal (-)heartburn, (-)rectal bleeding, (-)jaundice Genitourinary (-)frequency, (-) hematuria, (-) nocturia

33 Subjective Findings: PMHx
Past Medical History No previous surgeries Admitted at 1 y/o at Mary Johnson for amoebiasis Treated for Primary complex for 9 months No known co-morbids No known food or drug allergies

34 Subjective Findings Family history: Social history: Asthma Student
(-) Smoker (-) Alcohol drinker (-) Illicit drug user

35 Objective Findings: Vital Signs
Height: 160 cm Weight: 40.5 kg BMI: Underweight BP: 120/80 Temp: 37.5°C HR: 121 – tachycardic RR: 28 – tachypneic Abdominal Girth: 70 cm

36 Objective Findings: PE
Patient was alert, coherent but in severe pain Anicteric sclera, pink palpebral conjunctiva (-) TPC, (-) CLAD, (-) NVE Symmetric chest expansion, (-) chest retractions, (-) chest lag, bilaterally resonant with clear breath sounds, (-) adventitious breath sounds

37 Objective Findings: PE
Adynamic precordium, PMI at 5th LICS MCL, tachycardic, Regular rhythm, (-) murmurs Protruberant and distented, (-) surgical scars, hypoactive bowel sounds, direct and rebound tenderness on all quadrants DRE: Not done as per patient request. Full and equal pulses on all extremities, (-) edema, (-) cyanosis, CRT of 2 seconds

38 Objective Findings: Labs
Value Normal Remarks Hemoglobin 132 Low Hematocrit 0.36 WBC 8 4.5-10 Neutrophil 0.60 Lymphocyte 0.31 Eosinophil 0.02 Mean corpuscular Hgb 30.6 27-31 Mean corpuscular Hgb concentration 365 High Mean cell volume 83.8 80-96 RDW 12.2 Platelet 405

39 Objective Findings: Labs
URINALYSIS Dark amber, slightly turbid pH alkaline specific gravity 1.015 RBC 2-3 per hpf WBC 4-5 per hpf Epithelium Many Mucus threads Abundant Amorphous Phosphates Moderate Albumin (+) Sugar (-)

40 Objective Findings Labs
Value Normal Remarks Bleeding time 3 mins 5 secs 2-4 mins Clotting Time 3 mins 15 secs Prothrombin Time 12.9 10-13 PT control 12 INR 1.08 % Activity 89.6 PTT 30 29-34 PTT Control Creatinine 63.10 Na 132 Low K 3.8

41 Objective Findings CXR Clear lung fields Bony thorax intact
Heart magnified

42 Objective Findings

43 Objective Findings

44 Objective Findings

45 Salient Features 14 year old male
Persistent pain on hypogastrum with localization to LLQ On and off fever Diarrhea and vomiting Dysuria Abdominal Distention worsened by eating and relieved by vomiting Direct and Rebound Tenderness on all quadrants Rigidity X-ray Findings

46 Assessment Clinical Impression: Small Bowel Obstruction probably secondary to Ruptured Appendicitis Differentials : Peptic Ulcer Disease Ileus Meckel’s Diverticulum

47 Plan Diagnostic Plan: CBC Urinalysis Electrolytes Fecalysis
Abdominal X-ray CXR Ultrasound CT-Scan

48 Plan Treatment Plan Emergency Lapparatomy Appendectomy Hydration
Antibiotics Analgesics for pain NPO

49

50 Return to table

51 Subjective Findings MA, 18 F CC: anal discharge

52 Subjective Findings 4 Years PTA
Noted a rectal mass, R perianal area (+)Tender (-) tenesmus (-)pain on defecation (-) fecal retension (-) soiling of underwear (-) no discharge (-) change in bowel movements (-) itch/rashes (-) blood in stools Consult was done at another hospital Incision and drainage Condition resolved 4 Years PTA

53 Subjective Findings 1 year PTA
Pain on defecation (+)Soiling of underwear (+) Purulent discharge (+) yellowish discharge (-) anal mass (-) tenesmus (-) tenderness (-) blood in stools

54 Subjective Findings 1 week PTA
Increasing pain on defecation Brownish discharge Palpated right perianal mass larger than the previous (-) tenesmus (-) fecal retension (+) soiling of underwear (-) change in bowel movements (-) perianal itch/rashes (-) blood in stools

55 Subjective Findings 1 day PTA
(+) undocumented fever Persistence of symptoms prompted consult August 2, 2010, 4:30

56 Subjective Findings PMHx FHx P/S Hx s/p I & D 2006
No known medical illness No known allergy to food and drugs FHx (+) HPN Heart disease P/S Hx student Non-smoker Non-alcoholic beverage drinker Sexual Hx - denies sexual contact LMP: July 4, 2010

57 Objective Findings Physical Exam BP: 110/70 Temp: 37.1 C HR: 98 RR: 15
Pain Severity: 0/10

58 Objective Findings Gen: Alert, Coherent, not in cardiorespiratory distress HEENT: Anicteric sclera, pink palpebral conjunctiva, neck veins not engorged Pulmo: Symmetric chest , clear breath sounds, (-) Crackles and wheezing Caridio: Adynamic Precordium, Normal rate, Regular rhythm, (-) Murmur, good S1, S2

59 Objective Findings Abdomen Flat, soft abdomen Normoactive bowel sounds
tympanitic No palpable mass, No tenderness Extremities full and equal

60 Objective Findings Digital Rectal Exam
External opening 3 cm from anal verge. R posterior (7 o clock) (+) yellowish pus discharge Good external sphincter tone (-) blood in examining fingers (-) masses (-) induration

61 Assessment Fistula - in – ano Differentials 1. anal abscess 2. anal fissure

62

63

64

65 Inter Trans Supra extra

66 Plan Fistulotomy Curretage Healing by secondary intension Sitz bath
Biopsy of tract Possible use of drains/seton

67

68

69 Return to table

70 Subjective Findings GV, 45/F Residence: Taytay, Rizal
CC: recurrent RUQ abdominal pain for 11 years

71 Subjective Findings 11 years PTA 2 weeks PTA
Colicky RUQ pain radiating to the back (after eating a heavy meal) UTZ: cholelithiasis Meds: Buscopan Plus 500mg OD Same Sx + Abdominal fullness

72 Subjective Findings 8 hours PTA After a heavy fatty meal:
RUQ pain radiating to the back Severity score of 9/10 No relief: Buscopan Plus Admitted August 2, 2010; 4pm

73 Subjective Findings ROS:
(-) weight gain, fever, jaundice, change in bowel/micturition habits, changes in sensorium Current Medications: NO maintenance medications Vitamins: Myra-E OD Vit B

74 Subjective Findings Family History: Hypertension: mother
Past Medical History: No previous hospitalizations No allergies: food and medicines Surgeries: s/p Appendectomy: 1970’s s/p TAHBSO: stage II CA 2003 Family History: Hypertension: mother Gallstones: 3 brothers VACCINATION: (+) flu vaccine 8 mos ago

75 Subjective Findings Accountant Non-smoker Non-alcohol beverage drinker
No exercise Diet: Sweet Fatty Salty

76 Objective Findings Height 149cm Weight 52.6kg BMI 23.69 normal
BP 110/80 HR 80 RR 18 Temp 36.9 degrees Celsius

77 Objective Findings HEENT: anicteric sclera, pink palpebral conjunctivae, no TPC, no CLAD, no neck masses Chest: symmetrical chest expansion, resonant on percussion, clear breath sounds, no visible and palpable pulsations, distinct S1/S2, no murmurs

78 Objective findings Abdomen: no rigidity, no visible pulsations, surgical scars visible (8-9cm RLQ scar from a previous appendectomy procedure, 20-22cm horizontal scar from a previous TAHBSO procedure 10cm from the umbilicus), tympanitic on percussion, liver span 9cm at the MCL, no voluntary and involuntary guarding, smooth liver border, no palpable masses, (+) Murphy’s sign

79 Assessment Recurrent Calculous Cholecystitis Differentials:
Peptic Ulcer Disease Viral Hepatitis

80 Plan Surgical: Lap cholecystectomy (Dr. Cenon Alfonso)
Non-surgical Management: Antibiotics Analgesics Watch out for 5 W’s Advise on: Food: fatty

81 Return to table

82 General Data EA, 63/F CC: RUQ pain

83 HPI 1 Year PTA (+) intermittent epigastric and RUQ pain. Lasts for a few minutes. Associated with bloating. Alleviated by burping, flatus, massage of epigastrium. Aggravated with food intake. No radiations. Severity 1-2/10. -UTZ was done which revealed cholelithiasis.

84 Subjective Findings 1 year PTA
-Dx and Tx as peptic ulcer disease, was given unrecalled medicines w/c afforded temporary relief. - Persistence and progression of symptoms prompted consult and subsequent admission. Few weeks PTA ADMISSION

85 Subjective Findings ROS:
General: (+) Weakness, loss of appetite (-) Fever Musculo/Skin: (-) Rashes, joint pains, muscle pain HEENT: (+) Sinusitis, dizziness (-) Headache, blurring of vision, tinnitus, cough, colds, enlarged LN Resp: (-) Dyspnea, hemoptysis, wheeze Cardio: (+) Palpitations (-) Chest pains GI: (+) Heart burn, (-) Nausea, vomiting , change in bowel movements, rectal bleeding Genitourinary: (-) Nocturia,Dysuria, hematuria Endocrine: (-) Excessive sweat, heat intolerance, cold intolerance

86 Subjective Findings Past Medical History:
(+) Hypertension, controlled ~ 10 years Maintained on Losartan 50mg OD, Clonidine 75mg PRN. Normal BP: 130/80 (+) Asthma, controlled ~ 40 years, Maintained on Salbutamol and Fluticasone/Salmeterol (+) Anxiety DO, ~25 years Maintained on Alprazolam 500 mcg PRN (+) Dyspepsia, 1 year Maintained on antacids

87 Subjective Findings Past Medical History: Past Hospitalizations:
(–) Allergies to foods or medications No recent vaccinations Past Hospitalizations: R forearm fracture  closed reduction H. mole  D&C 1970 – PID 2° IUD  D&C 17 y/o, Asthma in Acute Exacerbation

88 Subjective Findings Family history:
(+) Gall stone - Daughter Social history: Non-smoker, non-alcoholic beverage drinker

89 Objective Findings BP: 140 / 80 Temp: 36.8°C HR: 78 RR: 20
Pain Severity: 0/10

90 Objective Findings Gen: Alert, coherent, afebrile, not in cardioresp distress HEENT: Anicteric sclera, pink palpebral conjunctiva, (–) TPC, (–) CLAD, flat neck veins Caridio: Adynamic precordium, Apex beat 5th LICS, MCL, Normal rate, Regular rhythm, (–) Murmur Pulmo: Symmetric chest expansion, Resonant lung fields, Clear breath sounds, (-) Crackles and wheezes

91 Objective Findings AB: Protuberant abdomen, NABS, tympanitic, soft, (–) Tenderness, Murphy’s sign, organomegaly, masses, surgical scars Extremities: Full and equal pulses, (–) edema, cyanosis, good turgor Skin: (–) Rashes, clean nails, dry hair

92 Salient Features 63/F Colicky RUQ pain Associated with bloating.
Aggravated with food intake Alleviated by burping, flatus, massage of epigastrium. No radiations. Severity 1-2/10. UTZ revealed cholelith in gallbladder.

93 Assessment Clinical Impression: Calculous Cholecystitis
Differentials : Peptic Ulcer Disease Cholangitis Hepatitis Acute Coronary Syndrome

94 Plan Diagnostic Plan: Abdominal Ultrasound CBC Hepatitis Serology ECG
UTZ: Sensi and speci > 95%

95 Plan Treatment Plan Cholecystectomy IV Fluids IV Antibiotics
IV Analgesics

96 Numerous pigmented stones, ranging from ~1x1cm

97 Return to table

98 Subjective Findings NV, 77/F CC: hip pain

99 Subjective Findings NOI: Fall POI: Paranaque City DOI: 8/1/10
TOI: 7 pm

100 Subjective Findings 2 hours PTA (+) sharp pain on movement
Inability to ambulate (+) numbness (-) swelling, pallor, paresthesia, discoloration, crepitus Xray done Pain meds, referred for surgery

101 Subjective Findings ROS (+) weight loss
(-) fatigue, weakness, joint pains (-) tingling sensation (-) loss of consciousness (-) difficulty breathing, tachypnea, cyanosis, chest pain

102 Subjective Findings ROS (-) fever (-) edema (-) skin changes, jaundice
(-) palpitations (-) chest pain (-) dysuria, hematuria, freq

103 Subjective Findings PMH/PSH Cervical spondylosis, OA (1993) HPN (1995)
Naproxen sodium Almitrine/ raubasine (30/10mg) HPN (1995) Amlodipine 5mg OD Patellar Fracture (2004)

104 Subjective Findings Obstetric history P/SH Post-menopausal Not on HRT
Non-smoker Non-alcoholic beverage drinker

105 Objective Findings VS RR: 18 HR: 86 T: 36.0 BP: 150/80

106 Objective Findings Primary Survey
A: (-) signs of airway obstruction, (-) cervical spine injury B: RR 18, (-) use of accessory muscles, SCE, patient is able to talk, lungs resonant, (-) cyanosis, (-) jugular venous distention, trachea midline

107 Objective Findings Primary Survey
C: BP 150/80, pulses full and equal, (-) cyanosis, T: 36.0 D: awake, alert, coherent. GCS 15, (-) motor, sensory deficits, (-) changes in mental status Radial 80mmhg Femoral/brachial 60 Carotid 40 mmhg

108 Objective Findings HEENT Pulmonary
Anicteric sclerae, pale palpebral conjunctivae, (-) TPC, (-) CLAD, flat neck veins Symmetric chest expansion, equal tactile fremiti, lungs resonant, minimal bilateral bibasal crackles

109 Objective Findings Cardiovascular Abdomen
Adynamic precordium, Apex beat: 6th ICS MCL, distinct S1 and S2, (-) murmurs Flabby, (-) surgical scars, (-) masses, NABS, (-) bruits, tympanitic, (-) tenderness, (-) organomegaly, (-) CVA tenderness

110 Objective Findings DRE Did not consent

111 Objective Findings Extremities L leg shorter and externally rotated
(+) L hip tenderness (+) LOM in affected limb (-) neurologic deficits (-) loss of pulse

112 Objective Findings Xray
Complete fracture with total displacement of fracture fragment

113 Assessment Femoral neck fracture Garden Type IV

114 Garden Classification
Femoral neck fractures as they are entirely within the joint capsule are not usually associated with hemodynamically significant blood loss. When fractures are displaced, disruption of blood flow to the femoral head is virtually certain. This, osteonecrosis of femoral head in displaced fractures is nearly inevitable.

115 Plan: Treatment Preoperative management Preoperative traction
Pressure-reducing mattresses Surgery performed once patient is medically stable (within 24 hours if possible) Hemiarthroplasty- replacing femoral neck and head with a metal and plastic prosthesis that fitss within the native acetabulum Surgery within 24 hrs: grad B recommendation ( inconsistent or limited evidence) Preop traction- no benefit for analgesia or ease of fraction reduction

116 Plan: Treatment Perioperative management
Operative tx is better than conservative tx Surgical technique Non displaced: screws better than pins Displaced: hemiarthroplasty or total hip arthroplasty Cemented arthroplasties superior to noncemented arthroplasties Operative better than conservative in preventing non-union, leg shortening, and deformity Hemi vs internal fixation depends upon patient factors/ surgeon preference

117 Plan: Treatment Perioperative management
Regional anesthesia (reduces morbidity and mortality) DVT prophylaxis for 10 days postoperatively Antibiotics preop: wound, urinary, respiratory Operative better than conservative in preventing non-union, leg shortening, and deformity

118 Plan: Treatment Early post-operative mgt (7-10 days)
Nutrition, protein supplementation for malnourished patients Initiate transition to rehabilitation Prevent complications: DVT, PE, bedsores, pneumonia Operative better than conservative in preventing non-union, leg shortening, and deformity

119 Plan: Treatment Rehabilitation/ discharge planning
Exercise programs improve function, length of stay, institutionalization, activity of daily living mobility, and ambulation Operative better than conservative in preventing non-union, leg shortening, and deformity

120 Prevention Prevent falls Increase physical activity
External hip protectors Combination of folate and mecobalamin(B12) Vitamin D, calcium, and bisphosphonates HRT

121 Screening Bone density scan (DEXA) for osteoporosis

122 Return to table

123 1 Subjective Findings M.M. 25M CC: abdominal pain

124 HPI 1 day PTC Subjective Findings Admission
1 day history of periumbilical pain Localized to RLQ after few hours Persistent 8/10 Not aggravated/relieved by eating No radiation (+) vomiting (+) anorexia (-) fever (-) change in bowel movement Persistence of pain prompted consult Admission

125 Subjective Findings ROS Past Medical No weight loss No cough/colds
1 Subjective Findings FH HPN Asthma PTB PS Non-smoker Non-alcoholic beverage drinker Obstetrics/gyne LMP: July 21 G1P1 (1001) S/P CS ROS No weight loss No cough/colds No dyspnea No chest pain Past Medical s/p CS 2007 Preeclampsia (+)Asthma 2-3 attacks per year Maintained on Salbutamol

126 Objective Findings On PE: Vitals Temp: 37.6 C,HR: 86 RR: 19 HEENT:
anicteric sclera, pink palpebral conjunctivae, moist tongue and buccal mucosa, Cardiopulmonary Equal chest expansion Clear breath sounds Normal rate and rhythm Good S1, S2, no murmurs

127 Objective Findings Abdomen: Extremities
1 Objective Findings Abdomen: I: flat, (+) infraumbilical scar midline (from previous CS) A: normoactive bowel sounds P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-) Rovsing’s (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphy’s sign , (-) Dunphy’s sign (+) CVA tenderness (R) Extremities Full and equal pulses, no edema, no cyanosis DRE: patient refused DRE

128 Assessment Impression: Acute Appendicitis Differentials UTI
1 Assessment Impression: Acute Appendicitis Differentials UTI Ureteral stones

129

130 Plan Diagnostic Plan Labs Imaging Pregnancy test Urinalysis CBC
1 Plan Diagnostic Plan Labs Pregnancy test Urinalysis CBC Imaging Abdominal Ultrasound CT scan of the abdomen RBC : 0-3 WBC: 6-8 No bacteria Moderate squamous CBC WBC 10.6 RBC 4.25 Hg: 123 Segmenters : 0.68 (.4-.6) Lymphocytes: (0.32)

131 Patients with scores of 9 to 10 are almost certain to have appendicitis; there is little advantage in further workup, and they should go to the operating room. Patients with scores of 7 to 8 have a high likelihood of appendicitis, while scores of 5 to 6 are compatible with, but not diagnostic of appendicitis. CT scanning is certainly appropriate for patients with Alvarado scores of 5 and 6, and a case can be built for imaging those with scores of 7 and 8. On the other hand, it is difficult to justify the expense, radiation exposure time, and possible complications of CT scanning in those patients whose scores of 0 to 4 make it extremely unlikely (but not impossible) that they have appendicitis.

132 Plan Treatment Plan Emergency Appendectomy
1 Plan Treatment Plan Emergency Appendectomy Final dx: Suppurative appendicitis Post op: antibiotics, pain relievers

133 Return to table

134 1 Subjective Findings M.M. 25M CC: abdominal pain

135 HPI 1 day PTC Subjective Findings Admission
1 day history of periumbilical pain Localized to RLQ after few hours Persistent 8/10 Not aggravated/relieved by eating No radiation (+) vomiting (+) anorexia (-) fever (-) change in bowel movement Persistence of pain prompted consult Admission

136 Subjective Findings ROS Past Medical No weight loss No cough/colds
1 Subjective Findings FH HPN Asthma PTB PS Non-smoker Non-alcoholic beverage drinker Obstetrics/gyne LMP: July 21 G1P1 (1001) S/P CS ROS No weight loss No cough/colds No dyspnea No chest pain Past Medical s/p CS 2007 Preeclampsia (+)Asthma 2-3 attacks per year Maintained on Salbutamol

137 Objective Findings On PE: Vitals Temp: 37.6 C,HR: 86 RR: 19 HEENT:
anicteric sclera, pink palpebral conjunctivae, moist tongue and buccal mucosa, Cardiopulmonary Equal chest expansion Clear breath sounds Normal rate and rhythm Good S1, S2, no murmurs

138 Objective Findings Abdomen: Extremities
1 Objective Findings Abdomen: I: flat, (+) infraumbilical scar midline (from previous CS) A: normoactive bowel sounds P: soft, (-) guarding, (+)RLQ pain direct and rebound, (-) Rovsing’s (+) Psoas and obturator sign, (-) cutaneous hyperesthesia, (-) Murphy’s sign , (-) Dunphy’s sign (+) CVA tenderness (R) Extremities Full and equal pulses, no edema, no cyanosis DRE: patient refused DRE

139 Assessment Impression: Acute Appendicitis Differentials UTI
1 Assessment Impression: Acute Appendicitis Differentials UTI Ureteral stones

140

141 Plan Diagnostic Plan Labs Imaging Pregnancy test Urinalysis CBC
1 Plan Diagnostic Plan Labs Pregnancy test Urinalysis CBC Imaging Abdominal Ultrasound CT scan of the abdomen RBC : 0-3 WBC: 6-8 No bacteria Moderate squamous CBC WBC 10.6 RBC 4.25 Hg: 123 Segmenters : 0.68 (.4-.6) Lymphocytes: (0.32)

142 Patients with scores of 9 to 10 are almost certain to have appendicitis; there is little advantage in further workup, and they should go to the operating room. Patients with scores of 7 to 8 have a high likelihood of appendicitis, while scores of 5 to 6 are compatible with, but not diagnostic of appendicitis. CT scanning is certainly appropriate for patients with Alvarado scores of 5 and 6, and a case can be built for imaging those with scores of 7 and 8. On the other hand, it is difficult to justify the expense, radiation exposure time, and possible complications of CT scanning in those patients whose scores of 0 to 4 make it extremely unlikely (but not impossible) that they have appendicitis.

143 Plan Treatment Plan Emergency Appendectomy
1 Plan Treatment Plan Emergency Appendectomy Final dx: Suppurative appendicitis Post op: antibiotics, pain relievers

144 RETURN TO TABLE


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