Cases! Flashcards
What is the general initial/immediate management of all surgical emergencies?
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) Bowel Rest - NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Cyclazine or Ondansetron)
9) Antibiotics: EXCEPT IN PANCREATITIS Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)
History: 18 ♀
PC:
Sudden onset right side lower abdominal since last night.
Vomited x 2
BO yesterday
No urinary symptoms
LMP 2 weeks ago
Past Med/Surg Hx: Diagnostic laparoscopy 2 years ago
Meds: Nil, NKDA
Review Of Systems:
- Nil of note
Physical Examination:
General Inspection:
Face flushed
Uncomfortable on bed
Vitals:
HR 96
BP 114/70
RR 15
Temperature 37.8
O2 sat 98% on Room Air
Abdomenal Examination:
Soft + Tender RIF
Guarding
No Rebound
Rovsing’s Sign Negative
QUICK Give your Differential diagnosis
What investigations would you carry out to rule out the differentials?
Differential Diagnosis:
Acute appendicitis
Ovarian Torsion
Ruptured ovarian cyst
Ectopic Pregnancy
Endometriosis
Mid cycle pain - Mittelschmerz
Small bowel obstruction (?Meckel’s diverticulum)
UTI
Abdominal CT
Pelvic US
B-HCG (serum or urine)
MSU for dipstick, culture, and sensitivity
History: 18 ♀
PC:
Sudden onset right side lower abdominal since last night.
Vomited x 2
BO yesterday
No urinary symptoms
LMP 2 weeks ago
Past Med/Surg Hx: Diagnostic laparoscopy 2 years ago
Meds: Nil, NKDA
Review Of Systems:
- Nil of note
Physical Examination:
General Inspection:
Face flushed
Uncomfortable on bed
Vitals:
HR 96
BP 114/70
RR 15
Temperature 37.8
O2 sat 98% on Room Air
Abdomenal Examination:
Soft + Tender RIF
Guarding
No Rebound
Rovsing’s Sign Negative
Investigation:
LABS:
FBC: Hb 13.1, WCC 12.9
CRP: 19
U&E: Ur 6.5, Cr 101, Na 139, K 4.1
Lactate: 1
Urinalysis:
Clear
β-HCG: negative
Ultrasound Pelvis is shown in the image below:
What is your most likely diagnosis?
What is your full management plan?
Ovarian Torsion
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) Bowel Rest - NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: EXCEPT IN PANCREATITIS Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)
Definitive Management:
Diagnostic Laparoscopy:
First Line: Detorsion and conservation. Give a little time after detorsion to see if blood supply returns. If no blood supply returns then:
Second line: Salpingo-oophorectomy
What is shown in the image?
How are they sorted? Based on what?
Which colour cannula is missing from this picture and what is it for?
IV cannulae
They are sorted based on the “Birmingham Gauge” which sorts them based on the thickness of the needle => the higher the G, the thinner the needle. Orange is the thickest (14G) which means it can output the largest flow (1L in 3.5 mins!) compared to the blue one which is 22G (1L in 22 mins)
All of these cannulae are used in adults and children. There is a missing cannula which is the yellow one (25G) which means it is the thinnest needle and is only used in infants
History: 53 ♀
Rapid onset severe upper abdominal pain x 2 days
Progressively worsening, previously intermittent, now constant
1st presentation
Nauseated, no vomiting
Last BO 2 days ago
No urinary symptoms
Meds: nil & NKDA ROS: NAD
Social Hx:
Non-smoker No C2H5OH
Family Hy: Mother gallbladder removed at 32
Physical Examination:
General:
Increased BMI
Uncomfortable
Vitals:
HR 110
BP 110/70
RR18
Temp 38.3
O2 sat 98%
Abdomen:
Soft
RUQ tenderness - severe
Guarding ++
Murphy’s sign positive
1) QUICK Give your differential diagnoses
2) Assume the patient also has rigors, what would you add to your differentials
3) What investigations would you carry out?
1) Acute cholecystitis
PUD
Acute Pancreatitis
Gastritis
Myocardial infarction
LowerLobe Pneumonia
UTI
2) !Acending Cholangitis!
[Pyelonephritis]
[Lobar pneumonia]
[Malaria]
3) Always bedside ECG
Bloods: FBC, U&E, LFTs, Amylase, CRP, Lactate
Urinalysis with dipstick, culture, and sensitivity. B-HCG
Erect CXR
US Gallbladder/Abdomen
History: 53 ♀
Rapid onset severe upper abdominal pain x 2 days
Progressively worsening, previously intermittent, now constant
1st presentation
Nauseated, no vomiting
Last BO 2 days ago
No urinary symptoms
Meds: nil & NKDA ROS: NAD
Social Hx:
Non-smoker No C2H5OH
Family Hy: Mother gallbladder removed at 32
Physical Examination:
General:
Increased BMI
Uncomfortable
Vitals:
HR 110
BP 110/70
RR18
Temp 38.3
O2 sat 98%
Abdomen:
Soft
RUQ tenderness - severe
Guarding ++
Murphy’s sign positive
1) Why would you order an Erect CXR?
2) What US would you order for this patient?
3) What findings would you be expecting to find on the US you ordered?
4) Define Sonographic Murphy’s Sign (for prof Arny)
1) Erect CXR to rule out perforation in PUD as the differential diagnosis
2) US Gallbladder/abdomen
3)
a) Gallbladder Distention
b) Wall thickening >3mm
c) Wall oedema (Double wall sign)
d) Pericholecystic fluid
e) Cholelithiasis (causing the acute cholecystitis)
f) Sonographic Murphy’s Sign (The abrupt cessation of inspiration due to presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder)
History: 53 ♀ weight 80kg
Rapid onset severe upper abdominal pain x 2 days
Progressively worsening, previously intermittent, now constant
1st presentation
Nauseated, no vomiting
Last BO 2 days ago
No urinary symptoms
Meds: nil & penicillin allergy ROS: NAD
Social Hx:
Non-smoker No C2H5OH
Family Hy: Mother gallbladder removed at 32
Physical Examination:
General:
Increased BMI
Uncomfortable
Vitals:
HR 110
BP 110/70
RR18
Temp 38.3
O2 sat 98%
Abdomen:
Soft
RUQ tenderness - severe
Guarding ++
Murphy’s sign positive
Labs Investigation:
FBC: Hb 11.5, WCC 13
U&E: Ur 6, Cr 73, Na 137, K 4.0
LFT’s: Bilirubin 10, AST 99, ALP, 195
Amylase: 62
CRP: 59
Lactate: 1.5
Urinalysis:
Clear
β-HCG: negative
Erect CXR normal
US Gall bladder in the picture and findings as follows:
US abdomen
GB wall thickening (>4-5 mm) or oedema (double wall sign)
Acoustic shadowing
No CBD dilation (CBD not often seen – or reliable)
“Sonographic Murphy’s sign“ positive
What is the most likely diagnosis?
What is your full management plan?
Acute Cholecystitis
Management:
Admit patient
Oxygen
IV Fluids – Hartmann’s Solution (compound sodium lactate, Bolus 10-20ml/Kg (Given lack of comorbidity or reason for loss of fluids, use 10) over 30 mins and then as maintenance fluids => 2700/24hrs 110ml/hr
Analgesia
Anti-emetics
Antibiotics – patient has penicillin allergy => Cefuroxime (instead of Co-amox) + Metronidazole
NPO [+/- NG]
Type and screen
DVT prophylaxis (Clexane + TEDs)
If calculous cholecystitis => remove calculus (detect via MRCP, remove via ERCP)
If acalculous and antibiotics do not work, or bad prognosis (liver cirrhosis, portal hypertension, diabetes) => Cholecystectomy
History: 73 ♂
Left lower abdo pain x 5 days
“Generally unwell” x 2 days
LBO 3 days ago – constipated
No nausea, vomiting, or blood PR
Nursing home resident – no previous diagnosis dementia
PMHx:
COPD
IHD, CCF, HTN
T2DM
Lap appx at 30, lap chole at 54
Meds: Ventolin PRN Aspirin Amlodipine Ramipril Furosemide Lactulose Metformin Gliclazide
Allergies:
Penicillin - Anaphylaxis
Physical Examination:
Uncomfortable, agitated
Disoriented time and place
Vitals:
HR 115
BP 105/70
RR 16
T 38.6
O2 sat 99% on 4L
Abdomen:
Tender LIF
Moderate guarding
No rebound tenderness
PR:
Empty rectum
No masses palpable
Give 5 ddx stating your most likely diagnosis
What labs will you order?
What is the diagnostic imaging will you order? and what findings are you looking for
Differentials:
Diverticulitis (most likely)
Volvulus
UTI/pyelonephritis
Mesenteric ischaemia
Colitis – infective vs inflammatory
Neoplasm
Bloods: FBC (High WCC, majority neutrophils!!), U&E (disturbances), CRP, Coag, blood cultures (if systemically unwell), amylase
Imaging: Diagnostic = CT abdomen showing
1) Segmental thickening of bowel
2) Pericolic abscess/distant abscess
LATER: Colonoscopy 6-8 weeks later to look for complications and malignancy
History: 73 ♂
Left lower abdo pain x 5 days
“Generally unwell” x 2 days
LBO 3 days ago – constipated
No nausea, vomiting, or blood PR
Nursing home resident – no previous diagnosis dementia
PMHx:
COPD
IHD, CCF, HTN
T2DM
Lap appx at 30, lap chole at 54
Meds: Ventolin PRN Aspirin Amlodipine Ramipril Furosemide Lactulose Metformin Gliclazide
Allergies:
Penicillin - Anaphylaxis
Physical Examination:
Uncomfortable, agitated
Disoriented time and place
Vitals:
HR 115
BP 105/70
RR 16
T 38.6
O2 sat 99% on 4L
Abdomen:
Tender LIF
Moderate guarding
No rebound tenderness
PR:
Empty rectum
No masses palpable
Lab Investigation:
FBC: Hb14.1 WCC 13.1
CRP 155
U&E: Ur 5.1 Cr 69 Na141 K3.5
LFT: Bil 12 AST 42 ALP 98
Amylase: 12
Coag: INR 1.1
Lactate: 1.8
Urinalysis: 10 pus cells
CT abdomen confirms segmental bowel thickening + a pelvic abscess.
What is your most likely diagnosis?
What classification is used in this case? How would you score this patient?
How would you manage this patient?
Acute Diverticulitis
Hinchey Classification II for Pelvic abscess
=> IV antibiotics + abscess drainage if abcess is >3cm and not in a sensitive location
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) Bowel Rest - NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Cyclazine or Ondansetron)
9) Antibiotics: EXCEPT IN PANCREATITIS Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)
History: 39 ♂
Severe rapid “plateau-like” onset epigastric pain x 8 hours
Radiating through to back – like a band across upper abdomen
Pain relieving by leaning forward
Vomiting x3 today
LBO today – loose
PMHx:
Renal calculus - 3 years ago
Gastritis – 1 year ago on OGD
C2H5OH 70 units/ week
Meds: Omeprazole 20mg OD
Give 5 ddx quickly, giving most likely diagnosis
What labs will you order? What are expected findings for your most likely diagnosis?
What immediate imaging would you order for this case? why?
Acute Pancreatitis (most likely)
Cholecystitis
PUD
Perforated DU
Gastritis/duodenitis
Ruptured AAA
Ureteric calculus
Lab Investigation:
FBC: raised Hb and WCC
CRP raised
U&E: increased creatinine
LFT:
Amylase: Extremely high (thousands)
Coag:
Lactate
Urinalysis:
Ultrasound to check for CBD dilation due to gallstone pancreatitis
History: 39 ♂
Severe rapid “plateau-like” onset epigastric pain x 8 hours
Radiating through to back – like a band across upper abdomen
Pain relieving by leaning forward
Vomiting x3 today
LBO today – loose
PMHx:
Renal calculus - 3 years ago
Gastritis – 1 year ago on OGD
C2H5OH 70 units/ week
Meds: Omeprazole 20mg OD
Lab Investigation:
FBC: Hb 12.4, WCC 14.3
CRP 35
U&E: Ur 7.9, Cr 102, Na 141, K 3.1
LFT: Bili 15, AST 30, ALP 121, GGT 720
Amylase: 1183
Coag: INR1.1
Lactate 1.3
Urinalysis: clear
Imaging shows no evidence of bile duct obstruction
What is the most likely diagnosis?
What classification is used to assess severity of your diagnosis? What would be considered severe?
List 5 early and 5 late complications of acute pancreatitis
How will you manage this patient?
Acute pancreatitis
Glasgow score (3+ = severe)
There is no curative treatment for acute pancreatitis => transfer to HDU or ICU if getting severe
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) Bowel Rest - NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Cyclazine or Ondansetron)
9) NO ANTIBIOTICS unless confirmed positive blood culture
10) DVT prophylaxis (TEDs, Clexane, LMWH)
History: 33 ♀
PC:
Sudden onset severe RUQ pain 8 hours previously
Shoulder-tip pain
Nauseated, no vomiting
Bowels opened earlier today
Intermittent RUQ pain worsening last 2 years
PMHx: Chronic back pain
Meds: Diclofenac
Allergies: Penicillin
Give 5 ddx stating your most likely diagnosis
What labs will you order?
What imaging would you order? What are you looking for?
Perforated duodenal/gastric ulcer (duodenal more common) - Most likely diagnosis
Bloods:
FBC w differentials (anemia and platelets)
Coag screen (coagulopathy and INR)
ABG - Rule out Ischemia (via lactate)
Group and Cross-match 4 units
Imaging:
!Erect! CXR for perforation -> pneumoperitoneum!
CT/CT angio to localize bleeding source
History: 33 ♀
PC:
Sudden onset severe RUQ pain 8 hours previously
Shoulder-tip pain
Nauseated, no vomiting
Bowels opened earlier today
Intermittent RUQ pain worsening last 2 years
PMHx: Chronic back pain
Meds: Diclofenac
Allergies: Penicillin
Lab Investigations
FBC: Hb 13.2, WCC 22.1 , Plt 632
CRP 210
U&E: Ur 5.1, Cr 96, Na+ 139, K+ 4.3
LFT: normal
Amylase 61
Coag: INR 1.0
Urinalysis: clear
What is your most likely diagnosis?
Finding is displayed in this image?
How will you manage this patient?
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)
Perforation => sepsis workup included with antibiotics (Coamoxiclav/Pip-taz + Metronidazole/Gentamicin)
=> Surgical treatment:
Gastric: Wedge Resection to exclude malignancy
Duodenum: Laparoscopic/open Graham Patch Repair (Ommental patch repair)
