Transcript ADMISSION CONFERENCE 2010

ADMISSION CONFERENCE 2010
ASMPH Clerkship – SURGERY ROTATION
St. Martin de Porres Charity Hospital
02 August 2010
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
Ileocecal
Tuberculosis,
Ulcerohypertrop
hic type
“E”
Small Bowel
Exploratory
Obstruction
Laparotomy,
probably 2’ to
Appendectom Ruptured AP
y
3
RM,42/M
Cholelithiasis
Lap Chole
Cholelithiasis
4
MA,18/F
Fistula in ano
Fistulotomy
Fistula in ano
Admissions from August 2-August 8, 2010
#
Patient ID Admitting
Diagnosis
5 GV,45/F
Calculous
Cholecystitis
Acute
6 EA,63/F
Cholecystitis
7 NV,77/F
Operation Done
Final Diagnosis
Lap
Cholecystectomy
Lap
Cholecystectomy
Calculous
Cholecystitis
Calculous
Cholecystitis
Femoral
Partial Hip
neck
replacement
fracture
Garden Type
IV
8 MM,25/M Acute
“E”
Appendicitis Appendectomy
Femoral neck
fracture
Garden Type IV
Ruptured
Appendicitis
General Data
• RJ, 23/M
• CC: RLQ pain
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.
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.
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.
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.
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.
Subjective Findings
• 1 mo PTA
- Repeat colonoscopy
was done, ileocecal TB
was considered.
- Surgery was
recommended due to
obstructive symptoms
hence admission.
ADMISSION
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
Subjective Findings
• Past Medical History:
– (+) Mumps, 13 y/o
– (–) Allergies to food or medicines
– (+) BCG
– (–) TB
Subjective Findings
• Family history:
– (+) Diabetes,
– (+) Hypertension
• Social history: Smoker; 1.6 pack years,
occasional alcoholic beverage drinker
Objective Findings
•
•
•
•
•
•
•
Height: 165cm
Weight: 42kg
BMI: 15
BP: 100 / 70
Temp: 36.7°C
HR: 106
RR: 22
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
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
Salient Features
• 23/M
• Colicky RLQ pain.
• Associated with bloating, vomiting, bulge in RLQ,
28% wt loss, fever, and alternating diarrhea (25x/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.
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
Dx Labs:
Salient Features
• (–) 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.
Assessment
• Primary Impression: Ileocecal Tuberculosis,
Ulcerohypertrophic type
• Differentials:
– Chronic Inflammatory Bowel Disease: Chron’s
– Lymphoma
– Colon Cancer
Plan
• Diagnostic Plan:
– CBC
– ESR
– PPD
– CXR
– CT abdomen
– AFB of biopsy
– PCR of biopsy
– Culture of biopsy
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
Text here
Right hemi? colectomy and
anastomosis
RETURN TO TABLE
Identifying Data
• JP, 15/M
• Date of birth: August 9, 1995
• Currently resides in Bonifacio Exit, Bagong
Silangan QC
• Date of admission: August 3, 2010. 9:45 am
• CC: Abdominal Pain and Distention
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
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
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
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
ADMISSION vomiting
Subjective Findings: ROS
• 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
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
Subjective Findings
• Family history:
– Asthma
• Social history:
– Student
– (-) Smoker
– (-) Alcohol drinker
– (-) Illicit drug user
Objective Findings: Vital Signs
•
•
•
•
•
•
•
•
Height: 160 cm
Weight: 40.5 kg
BMI: 15.8 - Underweight
BP: 120/80
Temp: 37.5°C
HR: 121 – tachycardic
RR: 28 – tachypneic
Abdominal Girth: 70 cm
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
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
Objective Findings: Labs
Value
Normal
Remarks
Hemoglobin
132
140-170
Low
Hematocrit
0.36
0.40-0.50
Low
WBC
8
4.5-10
Normal
Neutrophil
0.60
0.56-0.66
Normal
Lymphocyte
0.31
0.22-0.40
Normal
Eosinophil
0.02
0.01-0.04
Normal
Mean corpuscular
Hgb
30.6
27-31
Normal
Mean corpuscular Hgb
concentration
365
320-360
High
Mean cell volume
83.8
80-96
Normal
RDW
12.2
11.5-14.4
Normal
Platelet
405
150-350
High
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
(-)
Objective Findings Labs
Value
Normal
Remarks
Bleeding time
3 mins 5 secs
2-4 mins
Normal
Clotting Time
3 mins 15 secs
2-4 mins
Normal
Prothrombin Time
12.9
10-13
Normal
PT control
12
INR
1.08
% Activity
89.6
PTT
30
PTT Control
30
Creatinine
Normal
29-34
Normal
63.10
44.16-150.16
Normal
Na
132
138-146
Low
K
3.8
3.6-5.0
Normal
Objective Findings
• CXR
– Clear lung fields
– Bony thorax intact
– Heart magnified
Objective Findings
Objective Findings
Objective Findings
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
Assessment
• Clinical Impression: Small Bowel Obstruction
probably secondary to Ruptured Appendicitis
• Differentials :
– Peptic Ulcer Disease
– Ileus
– Meckel’s Diverticulum
Plan
• Diagnostic Plan:
– CBC
– Urinalysis
– Electrolytes
– Fecalysis
– Abdominal X-ray
– CXR
– Ultrasound
– CT-Scan
Plan
• Treatment Plan
– Emergency Lapparatomy Appendectomy
– Hydration
– Antibiotics
– Analgesics for pain
– NPO
RETURN TO TABLE
Subjective Findings
• MA, 18 F
• CC: anal discharge
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
Subjective Findings
1 year PTA
Pain on defecation
(+)Soiling of underwear
(+) Purulent discharge
(+) yellowish discharge
(-) anal mass
(-) tenesmus
(-) tenderness
(-) blood in stools
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
Subjective Findings
(+) undocumented fever
Persistence of symptoms
prompted consult
1 day PTA
August 2, 2010, 4:30
Subjective Findings
• PMHx
– 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
Objective Findings
Physical Exam
• BP: 110/70
• Temp: 37.1 C
• HR: 98
• RR: 15
• Pain Severity: 0/10
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
Objective Findings
• Abdomen
– Flat, soft abdomen
– Normoactive bowel sounds
– tympanitic
– No palpable mass, No tenderness
• Extremities
• full and equal
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
Assessment
Fistula - in – ano
Differentials
1. anal abscess
2. anal fissure
Plan
•
•
•
•
•
•
Fistulotomy
Curretage
Healing by secondary intension
Sitz bath
Biopsy of tract
Possible use of drains/seton
RETURN TO TABLE
Subjective Findings
• GV, 45/F
• Residence: Taytay, Rizal
• CC: recurrent RUQ abdominal pain for 11
years
Subjective Findings
• 11 years PTA
• Colicky RUQ pain
radiating to the back
(after eating a heavy
meal)
• UTZ: cholelithiasis
• Meds: Buscopan Plus
500mg OD
• 2 weeks PTA
• Same Sx + Abdominal
fullness
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
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
Subjective Findings
• 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
Subjective Findings
•
•
•
•
•
Accountant
Non-smoker
Non-alcohol beverage drinker
No exercise
Diet:
– Sweet
– Fatty
– Salty
Objective Findings
•
•
•
•
•
•
•
Height 149cm
Weight 52.6kg
BMI 23.69 normal
BP 110/80
HR 80
RR 18
Temp 36.9 degrees Celsius
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
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
Assessment
• Recurrent Calculous Cholecystitis
• Differentials:
– Peptic Ulcer Disease
– Viral Hepatitis
Plan
• Surgical: Lap cholecystectomy (Dr. Cenon
Alfonso)
• Non-surgical Management:
– Antibiotics
– Analgesics
– Watch out for 5 W’s
• Advise on:
– Food: fatty
RETURN TO TABLE
General Data
• EA, 63/F
• CC: RUQ pain
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.
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
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
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
Subjective Findings
• Past Medical History:
– (–) Allergies to foods or medications
– No recent vaccinations
• Past Hospitalizations:
– 2003 - R forearm fracture  closed reduction
– 1971 - H. mole  D&C
– 1970 – PID 2° IUD  D&C
– 17 y/o, Asthma in Acute Exacerbation
Subjective Findings
• Family history:
– (+) Gall stone - Daughter
• Social history: Non-smoker, non-alcoholic
beverage drinker
Objective Findings
•
•
•
•
•
BP: 140 / 80
Temp: 36.8°C
HR: 78
RR: 20
Pain Severity: 0/10
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
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
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.
Assessment
• Clinical Impression: Calculous Cholecystitis
• Differentials :
– Peptic Ulcer Disease
– Cholangitis
– Hepatitis
– Acute Coronary Syndrome
Plan
• Diagnostic Plan:
– Abdominal Ultrasound
– CBC
– Hepatitis Serology
– ECG
Plan
• Treatment Plan
– Cholecystectomy
– IV Fluids
– IV Antibiotics
– IV Analgesics
Numerous pigmented stones, ranging from ~1x1cm
RETURN TO TABLE
Subjective Findings
• NV, 77/F
• CC: hip pain
Subjective Findings
•
•
•
•
NOI: Fall
POI: Paranaque City
DOI: 8/1/10
TOI: 7 pm
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
Subjective Findings
• ROS
•
•
•
•
•
(+) weight loss
(-) fatigue, weakness, joint pains
(-) tingling sensation
(-) loss of consciousness
(-) difficulty breathing,
tachypnea, cyanosis, chest pain
Subjective Findings
• ROS
•
•
•
•
•
•
(-) fever
(-) edema
(-) skin changes, jaundice
(-) palpitations
(-) chest pain
(-) dysuria, hematuria, freq
Subjective Findings
• PMH/PSH
• Cervical spondylosis, OA
(1993)
– Naproxen sodium
– Almitrine/ raubasine
(30/10mg)
• HPN (1995)
– Amlodipine 5mg OD
• Patellar Fracture (2004)
Subjective Findings
• Obstetric history
• P/SH
•
•
•
•
Post-menopausal
Not on HRT
Non-smoker
Non-alcoholic beverage
drinker
Objective Findings
• VS
•
•
•
•
RR: 18
HR: 86
T: 36.0
BP: 150/80
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
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
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
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
Objective Findings
• DRE
Did not consent
Objective Findings
• Extremities
• L leg shorter and
externally rotated
• (+) L hip tenderness
• (+) LOM in affected limb
• (-) neurologic deficits
• (-) loss of pulse
Objective Findings
• Xray
• Complete fracture with
total displacement of
fracture fragment
Assessment
Femoral neck fracture
Garden Type IV
Garden Classification
Plan: Treatment
• Preoperative management
– Preoperative traction
– Pressure-reducing mattresses
– Surgery performed once patient is medically
stable (within 24 hours if possible)
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
Plan: Treatment
• Perioperative management
– Regional anesthesia (reduces morbidity and
mortality)
– DVT prophylaxis for 10 days postoperatively
– Antibiotics preop: wound, urinary, respiratory
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
Plan: Treatment
• Rehabilitation/ discharge planning
– Exercise programs improve function, length of
stay, institutionalization, activity of daily living
mobility, and ambulation
Prevention
•
•
•
•
•
•
Prevent falls
Increase physical activity
External hip protectors
Combination of folate and mecobalamin(B12)
Vitamin D, calcium, and bisphosphonates
HRT
Screening
• Bone density scan (DEXA) for osteoporosis
RETURN TO TABLE
1
Subjective Findings
• M.M. 25M
• CC: abdominal pain
1
Subjective Findings
HPI
1 day PTC
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
1
Subjective Findings
• ROS
– No weight loss
– No cough/colds
– No dyspnea
– No chest pain
• Past Medical
s/p CS 2007
Preeclampsia
(+)Asthma
FH
• HPN
• Asthma
• PTB
• PS
Non-smoker
Non-alcoholic beverage
drinker
• Obstetrics/gyne
• LMP: July 21
• G1P1 (1001)
• S/P CS
1
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
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
1
Assessment
• Impression: Acute Appendicitis
• Differentials
– UTI
– Ureteral stones
1
Plan
• Diagnostic Plan
• Labs
– Pregnancy test
– Urinalysis
– CBC
• Imaging
– Abdominal Ultrasound
– CT scan of the abdomen
1
Plan
• Treatment Plan
– Emergency Appendectomy
• Final dx: Suppurative appendicitis
– Post op: antibiotics, pain relievers
RETURN TO TABLE
1
Subjective Findings
• M.M. 25M
• CC: abdominal pain
1
Subjective Findings
HPI
1 day PTC
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
1
Subjective Findings
• ROS
– No weight loss
– No cough/colds
– No dyspnea
– No chest pain
• Past Medical
s/p CS 2007
Preeclampsia
(+)Asthma
FH
• HPN
• Asthma
• PTB
• PS
Non-smoker
Non-alcoholic beverage
drinker
• Obstetrics/gyne
• LMP: July 21
• G1P1 (1001)
• S/P CS
1
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
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
1
Assessment
• Impression: Acute Appendicitis
• Differentials
– UTI
– Ureteral stones
1
Plan
• Diagnostic Plan
• Labs
– Pregnancy test
– Urinalysis
– CBC
• Imaging
– Abdominal Ultrasound
– CT scan of the abdomen
1
Plan
• Treatment Plan
– Emergency Appendectomy
• Final dx: Suppurative appendicitis
– Post op: antibiotics, pain relievers
RETURN TO TABLE