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Surgery Kaplan

CASE 1

Right sided Abdominal pain, Hx suggestive of Appendicitis.

Initial Ix

CBC : WBC 150000

BMP

Flat and upright abd X ray / Chest X ray : RLQ fecalith

Urianalysis

If atypical presentation CT scan may be indicated to confirm but usually


if clinically very suggestive we don’t need.

Mx –

NPO

IV rd Gen Chephalosporin

Sx

Missed appendicitis – after 5 days of pain

Mx –

Admit the patient { mmonitor, pain, appetitite, WBC count }

NOP

IV fluids / IV antibiotics

CT scan

If resolves bring patient in 6 weeks.

If not resolve >>> CT > localized CT guided drain.

If burst >> resutitate and proceed to surgery


Mecals diverticulum __ clinically indistugishalbe so if you find Appendix
normal search the small bowel 2 feet from ileocecal valve.

CASE 2 .

Problem with breathing. After RTA. BP l10 /70 , pulse 115 , RR 30.

Head to toe examine

Inital IX –

ABCE

X ray – C spine , chest , Pelvis { pubic ramus fracture +}

CBC

Blood group and DT

12 lead ECG

BMP

Amylase

Blood alcohol

Pulse oxy

NG tube

Foley catheter if no meatal blood

Further Ix :

CT scan head non contrast

Urine analysis

CT abdomen/ pelvis with contrast

Rx –

Admit to ICU

Serial CBC
NPO

Serial abdominal and neurology exam

Continuos cardiac moinitor

Echo

Troponin if cardiac contusion suspected.

Orthopedic consult.

Mx –

Shock : commonest type hypovolemic

Give fluid and blood .

Cardiogenic : rare little bit , contusion or cardiac tamponade

Tension penumothorax, acute MI or heart failure

Neurogenic : spinal injury.

If reduced level of consciousness for any cause : even if they have head
trauma or alcohol ::::: do CT abdomen because they cant tell if anything
goin in the abdomen.

Pelvic fracture : venous bleeding , can’t operate

Pelvic stabilization , binder / external pelvic fixation

If it doesn’t stabilized angiographic arterial emobolization ; bilateral


hypogastric / internal iliac arteries , not external iliac {legs will fall
out} , not venous { concern is to reduce inflow}

If any signs for cervical fracture/ patients may not tell anything but do
the CT neck or MRI to confirm if some suspiciousness , X rays are not very
sensitive.
CASE 2.

Left foot pain acute onset / Hx suggestive of embolization secondary to


Atrial fibrillation.

Ix –

5 Ps , {pulseless, pallor, poillothermic, peritic /weakning}

Ix –

EKG/ ECHO
CXR

Immedicate Iv heparin.

Left angiogram if time permits { critical ischemia from onset of pain , <
4 h presentation} , if not angio at the theatre}

Rx

Heparinise

Emergency surgical embolectomy

CASE 4

RUQ pain , PHx – of on off pain now continous

Vitals – 38 F , BP normal , pulse 105 , skin sclera ; no jaundice ..

Marked RUQ and mid epigastric tenderness with rebound tenderness+

DDs – biliary tract , gastric ulcer sometimes

Ix – -

CBC WBC high

BMP

Amylase
USS abdomen : stones ? , thickened gall bladder wall , edema , dilated
ducts }

HIDA scan : if USS normal , acalculous cholysititis suggestive

CCK HIDA scan : functional gall bladder abnormality is suspected / biliary


diskinesia.

X ray abdomen {cholesterol stones sometimes visible}

For free air best test is Upright CXR {if not left lateral decubitus
abdomen X ray}

Urinanalysis

Urine HCG

Rx – admit

NPO

IV antibiotics/ iVF

Cholecystectomy when no pain, WBC is normal

If no resolution in within 48 h >>>>>>>>>>> do Lap choli

If resolves :>>>> earlier cholecystectomy was done after 6-8 weeks / but
since patients are not compliant do Sx on this admission

Murphys sign + / very sick ; WBC very high / Low BP /altered mental signs
{ sepsis}

You must drain the patient ... by ERCP decompression or percutanious


drainage. And once pt cools down take gall bladder out.

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