Download Surg PPT

Presentation
Diagnosis
Workup
Treatment
Notes
35 yo M s/p fall from ladder, c/o R chest pain, SOB.
Exam shows tender R ribs, subcutaneous emphysema,
absent R breath sounds, JVD, tracheal deviation to L.
HR 130, BP 80/40, SaO2 92%.
Tension pneumothorax
Unstable: none (act on clinical diagnosis)
Stable: CXR
Unstable: needle decompression
Stable: chest tube
Tension pneumothorax is a clinical diagnosis and requires
immediate decompression if unstable.
Causes cardiovascular collapse due to loss of preload.
Presentation
Diagnosis
Workup
Treatment
Notes
60 yo F c/o vomiting x 2 days, crampy abdominal pain,
no flatus or BMs. Exam shows distended, tympanitic
abdomen, high-pitched tinkling bowel sounds. Only
PMH is TAH/BSO 20 yrs ago.
Small bowel obstruction
AXR: distended loops with air-fluid levels
Stable: IVF (saline), NGT, trial of observation
Unstable or complete obstruction: laparotomy, lysis of
adhesions
Most common cause of small bowel obstruction in U.S.
adults is adhesions from prior surgery.
Incarcerated hernia is most common cause in children and
and adults worldwide.
Presentation
Diagnosis
Workup
Treatment
Notes
30 yo F c/o neck mass. Exam shows 2 cm discreet, firm,
nontender nodule in L thyroid.
Thyroid nodule
FNA
Suspicious or malignant: operation
Benign: observation with repeat FNA
FNA is test of choice, not radioiodine scan.
Cold nodule is more likely cancer than hot nodule.
Presentation
Diagnosis
Workup
Treatment
Notes
20 yo M s/p high-speed MVC. Initial CXR shows
widened mediastinum.
Aortic transection
Definitive test in stable patient: aortogram
Unstable: pursue abdominal causes
Operation
Do not send any unstable patients to radiology.
Most aortic transection patients die at scene.
Transection (a tear) is different than dissection (an intimal
flap).
Angiography is gold standard test for most vascular
issues.
Presentation
Diagnosis
Workup
Treatment
Notes
38 yo M s/p ATV crash. Exam shows unstable pelvis,
high-riding prostate on rectal exam, scrotal hematoma,
and blood at the urethral meatus. Foley?
Urethral transection
Retrograde urethrogram
Suprapubic cystostomy tube
Do not place a foley in a trauma patient with blood at the
urethral meatus.
Presentation
Diagnosis
Workup
Treatment
Notes
30 yo F s/p thryoidectomy, develops acute stridor on the
ward. Exam shows cyanotic patient with tense,
swollen neck wound. RR 40, Sa02 70%.
Postop hemorrhage with airway compression
None
Open wound at bedside and evacuate hematoma
Tricky, because intubation seems like the first step, but
often is not possible. Opening wound is faster.
Bilateral recurrent laryngeal nerve injury less likely,
would have presented earlier.
Presentation
Diagnosis
Workup
Treatment
Notes
50 yo M c/o substernal chest pain 4 hrs following EGD.
Exam shows subcutaneous emphysema at inferior
neck. Stat CXR shows pneumomediastinum.
Esophageal perforation
Oral contrast study
Operation
Most important prognostic factor is duration of
perforation.
Timely diagnosis and treatment is critical.
Presentation
Diagnosis
Workup
Treatment
Notes
45 yo F c/o RUQ pain, fever, chills. Exam shows
diaphoresis, sclericterus, tender RUQ. Temp 39.0, HR
110, BP 100/60, WBC 22, T bili 5.0, Alk phos 300.
Cholangitis
Ultrasound of RUQ
IVF, IV antibiotics
Urgent biliary decompression (ERCP or percutaneous
transhepatic)
Cholangitis is biliary pus under pressure.
Charcot triad: fever, jaundice, RUQ pain.
Reynold pentad: add hypotension, mental status changes.
Presentation
Diagnosis
Workup
Treatment
Notes
75 yo M smoker c/o episodes of partial vision loss in R
eye, as well as episodes of L hand numbess, weakness.
Exam shows bruit in R neck.
Carotid stenosis
Carotid duplex US
Angiography (for operative planning)
Carotid endarterectomy
Amaurosis fugax: transient monocular blindness.
Emboli from carotid to opthalmic to retinal arteries.
Degree of bruit does not correlate with degree of stenosis.
Presentation
Diagnosis
Workup
Treatment
Notes
18 yo M s/p gunshot wound to abdomen. Exam shows
bullet wound in LUQ. HR 90, BP 120/80.
Penetrating trauma to the abdomen
None
Laparotomy
Penetrating abdominal trauma is a freebie. GSW or stab
wound to abdomen always goes to the OR.
Presentation
Diagnosis
Workup
Treatment
Notes
18 yo M s/p stab wound to chest. Wound is medial to L
nipple. Exam shows B breath sounds, muffled heart
sounds, and JVD. HR 140, BP 75/40, Sa02 99%.
Pericardial tamponade
Unstable: none
Stable: echo
Pericardiocentesis or subxyphoid window
Beck triad: muffled heart sounds, JVD, hypotension.
Presentation
Diagnosis
Workup
Treatment
Notes
40 yo M c/o sudden upper abdominal pain. Exam shows
tender epigastrium, guarding, rebound. AXRs show
free air under the diaphragm. PMH significant for
chronic back pain, NSAID use.
Acute abdomen, perforated peptic ulcer
Nothing further
Laparotomy
“Free air” always goes to the OR.
Presentation
Diagnosis
Workup
Treatment
Notes
2 day old M infant with abdominal distension and failure
to pass meconium.
Hirschsprung’s disease
(Initial) Contrast enema: constricted distal colon, dilated
proximal colon
(Definitive) Rectal biopsy: aganglionosis
Operation (diversion, resection, reconstruction)
Can also present as chronic constipation in infant.
Presentation
Diagnosis
21 yo M c/o 24 hrs of progressive abdominal pain, first
periumbilical, now RLQ. Nausea, vomiting, anorexia.
Exam shows tap tenderness in RLQ, guarding,
rebound, and pain in RLQ with palpation in LLQ.
Temp 38.8, WBC 14.
Appendicitis
Workup
Nothing further
Treatment
Appendectomy
Notes
If given classic appendicitis… please, please take to OR.
Presentation
Diagnosis
Workup
Treatment
Notes
40 yo M c/o chronic L groin mass, now acutely painful.
Exam shows large, soft, tender mass at L groin.
Inguinal hernia
None
Reducible: elective hernia repair
Non-reducible (incarcerated): emergent exploration
Incarcerated hernia is a freebie. Always goes to the OR.
Presentation
70 yo M c/o fatigue. Exam is benign except hemepositive rectal exam. Hct is 29.
Diagnosis
Colon cancer
Workup
Colonoscopy
Treatment
Notes
Colon cancer: partial colectomy
Positive lymph nodes: postop chemo
Hepatic metastasis: resect if possible
Most common site of spread is to liver, so check preop
LFTs.
CEA is not good for screening, but can be used to indicate
recurrence.
No radiation for colon cancer, unlike rectal cancer.
Presentation
Diagnosis
Workup
Treatment
Notes
60 yo F struck by softball in L flank, c/o abdominal pain,
L shoulder pain. Exam shows tender LUQ. HR 80,
BP 140/70, WBC 10, Hct 32.
Splenic injury
CT of abdomen/pelvis
Stable: ICU observation, serial Hcts, serial exams,
transfusion prn
Unstable: laparotomy, splenectomy or repair
Blunt trauma to spleen and liver is treated non-operatively
if possible. Go to OR for hemodynamic instability,
massive transfusion requirements.
Risk of splenectomy is overwhelming post-splenectomy
sepsis due to encapsulated organisms. Vaccinate
against strep pneumo, meningococcus, and h flu.
Presentation
Diagnosis
Workup
Treatment
Notes
70 yo F c/o fevers, abdominal pain. Exam shows tender
LLQ, no peritoneal signs. Temp 38.5, WBC 18.
Diverticulitis
CT scan of abdomen/pelvis
Inflammation only: bowel rest, antibiotics
Abscess: percutaneous drainage
Gross perforation, free fluid: operation
No colonoscopy in suspected diverticulitis.
Pneumaturia: colovesical fistula due to diverticulitis.
Presentation
Diagnosis
Workup
Treatment
Notes
25 yo F c/o 6 months of bloody loose bowel movements,
diarrhea, crampy abdominal pain.
Ulcerative colitis or Crohn’s
Colonoscopy
Primarily medical: sulfa drugs, steroids, anti-metabolites
Surgery for refractory cases and complications
(perforation, obstruction, fistula, bleeding, stricture,
toxic megacolon)
Crohn’s: mouth-to-anus with skip areas, transmural,
granulomas, cobblestoning,
UC: continuous in rectum and colon only, mucosal,
pseudopolyps, toxic megacolon, cancer
Presentation
Diagnosis
Workup
Treatment
Notes
65 yo M smoker c/o pain in L calf with ambulation. Pain
begins at certain walking distance, then relieved by
rest. Exam shows pink, warm feet without palpable
pedal pulses. Neuromotor exam intact.
Claudication (peripheral vascular disease)
Hand-held doppler, ankle-brachial indices
Non-invasive arterial doppler (duplex) studies
Angiography (for operative planning)
Initial: stop smoking and exercise more
Most patients with claudication do not progress to require
operation.
Intervention or surgery reserved for severe claudication,
rest pain, or tissue loss
Presentation
80 yo M w/ dementia, bedridden, brought from nursing
home for abdominal distension, pain. No vomiting,
no BMs. Exam shows massively distended abdomen,
mild diffuse tenderness. Temp 37.0, WBC 10. AXR
shows greatly distended colon with distal bird’s beak.
Diagnosis
Sigmoid volvulus
Workup
AXRs, BE or CT
Treatment
Notes
Stable: sigmoidoscopic reduction, then elective resection
Unstable or peritoneal signs: laparotomy
50% recurrence rate, therefore resect sigmoid same
hospitalization
Presentation
Diagnosis
Workup
Treatment
Notes
50 yo M w/ Hep B, Hep C, ETOH abuse, and cirrhosis,
c/o 6 mos of vague abdominal pain, weight loss.
Exam shows nontender abdomen with firm fullness in
RUQ. Labs show elevated AFP.
Hepatocellular carcinoma
CT of abdomen/pelvis
Resection
Marker for HCC is alpha-fetoprotein (AFP).
HCC is most common cancer worldwide.
Presentation
40 yo F c/o acute RUQ pain following fatty meal. Exam
shows tender RUQ, plus inspiratory arrest on deep
palpation. Temp 38.7, WBC 15.
Diagnosis
Acute cholecystitis
Workup
Ultrasound of RUQ
Treatment
Notes
Laparoscopic cholecystectomy
Prohibitive OR risk: percutaneous cholecystostomy tube
Gallstones, but no symptoms? No lap chole.
Presentation
Diagnosis
Workup
Treatment
Notes
40 yo M w/ ETOH abuse c/o severe epigastric pain
radiating to back, nausea, vomiting. Exam shows
tender epigastrium, quiet abdomen. Temp 38.5, HR
120, BP 90/60, WBC 18, lipase 1400.
Acute pancreatitis
CT of abdomen/pelvis
Resuscitation!
IVF, NPO, NGT, analgesia
Most common causes of pancreatitis: gallstones, ETOH.
Surgery usually reserved for complications of
pancreatitis: infected necrosis, bleeding, pseudocysts.
Presentation
Diagnosis
50 yo F c/o muscle pain, bone pain, depression, kidney
stones. Exam is benign. Serum Ca is 12.5.
Hyperparathryoidism
Workup
Ca level, PTH level
Sestamibi scan
Treatment
Parathyroidectomy
Notes
Primary hyperPTH: adenoma
Secondary: hyperplasia due to renal failure, low Ca
In outpatients, most common cause of hypercalcemia is
hyperPTH.
In inpatients, is bony metastases (e.g., breast cancer).
Presentation
Diagnosis
Workup
50 yo F c/o headaches, episodic sweating, and
palpitations. Exam is benign. HR 95, BP 180/110.
Pheochromocytoma
Urine catecholamines (VMA, metanephrines)
CT or MRI, MIBG, adrenal vein sampling
Treatment
Adrenalectomy
Preop alpha-blockers, IVF, then beta-blockers if needed
Notes
Risk of intraop hypertensive crisis.
MEN 1: parathyroid, pancreas, pituitary.
MEN 2a: pheo, medullary thyroid, hyperPTH.
MEN 2b: pheo, medullary thyroid, mucosal neuromas.
Presentation
Diagnosis
Workup
Treatment
Notes
6 week old M infant has 2 days of nonbilious, projectile
vomiting. Exam shows dry mucous membranes,
rubbery “olive” size mass in epigastrium.
Hypertrophic pyloric stenosis
US or UGI contrast study
Initial: resuscitation (saline)
Definitive: pyloromyotomy
Gastric acid loss causes hypokalemic, hypochloremic
metabolic alkalosis with paradoxic aciduria.
Kidneys preserve Na at expense of H and K.
Same situation with chronic NGT loss in postop patients
or vomiting adults.
Presentation
Diagnosis
Workup
Treatment
Notes
7 day old F with sudden onset bilious vomiting.
Malrotation until proven otherwise
Upper GI contrast study: jejunum starts R of midline
Emergent laparotomy (detorsion of volvulus)
Probably the most important algorithm in peds surgery.
Bilious vomiting in a neonate is malrotation until proven
otherwise.
No radiology? Take to OR to r/o malrotation.
Presentation
Diagnosis
Workup
Treatment
Notes
70 yo M smoker c/o acute abdominal pain that radiates to
back. Exam shows palpable, pulsatile abdominal
mass. HR 130, BP 80/40.
Abdominal aortic aneurysm
Unstable, ruptured: none
Stable: CT or US
Open or endovascular repair
Elective repair generally indicated for AAA diameter
cm or more.
Don’t send any unstable patients to radiology.
5
Presentation
Diagnosis
Workup
Treatment
Notes
60 yo M c/o yellow eyes, dark urine, light stools. No
other symptoms. Exam shows jaundice.
Pancreatic cancer
CT of abdomen
Pancreaticoduodenectomy (Whipple)
Painless jaundice is pancreatic cancer until proven
otherwise.
Presentation
Diagnosis
Workup
Treatment
Notes
40 yo F on the ventilator s/p sigmoid colectomy.
Following central line placement into the L internal
jugular, she becomes acutely tachycardic and
hypotensive. Absent L breath sounds.
Tension pneumothorax
Unstable: none (act on clinical diagnosis)
Stable: CXR
Unstable: needle decompression
Stable: chest tube
Tension pneumothorax is a clinical diagnosis and requires
immediate decompression if unstable.
Causes cardiovascular collapse due to loss of preload.