Kaplan Test USMLE Step 2 CK Lecture Notes Surgery TX Adil Farooqui, MD, FRCS Clinical Assistant Professor of Surgery Keck School of Medicine. USMLE Step 2 CK Lecture Notes 5-Book Set (USMLE Prep) 1st Edition USMLE Step 1st Edition The only official lecture notes provided by Kaplan Medical, USMLE Step 2 CK Lecture The set includes: Internal Medicine . Download Step 2 CK Lecture Notes Internal Medicine PDF Free. The only official Kaplan Lecture Notes for USMLE Step 2 CK cover the comprehensive.
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If there is an obvious vascular injury absent distal pulses, expanding hematoma surgical exploration and repair are required. Simultaneous injuries of arteries and bone pose the challenge of the sequence of operative repair.
One perspective is to stabilize the bone first, then do the delicate vascular repair which could otherwise be disrupted by the bony reduction and fixation. However during the orthopedic repair, ongoing ischemia is occurring as the arterial flow is disrupted.
A good solution, if proposed on the exam, is to place a vascular shunt, which allows temporary revascularization during the bony repair, with definitive vascular repair completed subsequently.
A fasciotomy should usually be added because prolonged ischemia could lead to a compartment syndrome. High-velocity gunshot wounds e. Crushing injuries of the extremities resulting in myonecrosis pose the hazard of hyperkalemia and renal failure as well as potential development of compartment syndrome.
Aggressive fluid administration, osmotic diuretics, and alkalinization of the urine with sodium bicarbonate are good preventive measures for the acute kidney injury, and a fasciotomy may be required to prevent or treat compartment syndrome.
Alkaline burns Liquid Plumr, Drano are worse than acid burns battery acid. Irrigation must begin as soon as possible at the site where the injury occurred tap water, shower.
Do not attempt to neutralize the agent. High-voltage electrical burns are always deeper and worse than they appear to be. Massive debridements or amputations may be required. Additional concerns include myonecrosis-induced acute kidney injury, orthopedic injuries secondary to massive muscle contractions e.
Of course cardiac electrical integrity and function must be evaluated. Respiratory burns inhalation injuries occur with flame burns in an enclosed space a burning building, car, plane and are chemical injuries caused by smoke inhalation. Burns around the mouth or soot inside the throat are suggestive clues. Diagnosis is confirmed with fiberoptic bronchoscopy, but the key issue is whether respiratory support is necessary, guided by serial arterial blood gases. Intubation should be initiated if there is any concern about adequacy of the airway.
This can also occur in circumferential burns to the chest, with resultant limitations in ventilation. Escharotomies of insensate full-thickness burns can be done at the bedside with no need for anesthesia to provide immediate relief. Scalding burns in children should always raise the suspicion of child abuse, particularly if the pattern of the burn does not fit the description of the event given by the parents.
A classic example is burns of both buttocks, which are typically produced by holding a small child by rbaygell arms and legs and dunking him into boiling water. Burns differ importantly from other types of traumatic injury. Burns result in the loss of skin integrity and increase insensible fluid losses, leading to profound hypovolemia and loss of temperature control. When in doubt consult a burn center before initiating fluid resuscitation or other interventions. In the first 24 hours after burn, fluid needs can be estimated by calculations that take into account the extent of the burn and provide an estimated amount of IV fluid that is needed.
Once fluid resuscitation has been initiated, adjust rate based on urinary output. For purposes of this calculation, only partial and full thickness previously referred to as second- and third-degree burns count. The 24 hour time window for burn resuscitation begins from the time of the burn injury! Parkland Formula: Alternative strategy: Fluids containing glucose are avoided to prevent an osmotic diuresis that would render urine output unreliable and exacerbate hypovolemia.
Fluid needs for burned babies differ from adults in several respects. Third-degree burns in babies look deep red rather than the leathery, dry, gray appearance present in adults. Other aspects of burn care include tetanus prophylaxis, cleaning of the burn areas, and the use of topical agents. The standard topical agent is silver sulfadiazine. If a topical agent with deep penetration is necessary e. Burns near the eyes are covered with bacitracin or triple antibiotic ointment silver sulfadiazine is irritating to the eyes.
In the early period, all pain medication is given intravenously because GI absorption is unpredictable. After 2 or 3 weeks of wound care and general support, the burned areas which have not regenerated are grafted.
Rehabilitation starts on day 1. When possible, early excision and skin grafting are recommended to save costs and minimize pain, suffering, and complications. Dog bites are considered provoked if the dog was petted while eating or otherwise teased. No rabies prophylaxis is required, other than observation of the dog for developing signs of rabies.
Unprovoked dog bites or bites from wild animals raise the issue of potential rabies. If the animal is available, it can be euthanized and the brain examined for signs of rabies.
Otherwise, rabies prophylaxis with immunoglobulin plus vaccine is mandatory. The most reliable signs of envenomation are severe local pain, swelling, and discoloration developing within 30 minutes of the bite. If such signs are present, draw blood for typing and crossmatch they cannot be done later if needed , coagulation studies, and liver and renal function. Treatment is based on antivenin. Antivenin dosage relates to the size of the envenomation, not the size of the patient children get the same dosages as adults.
Surgical excision of the bite site or fasciotomy is very rarely needed. The only valid first aid is to splint the extremity during transportation. Do not make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet. Bee stings kill many more people in the United States than snakebites because of an anaphylactic reaction. Epinephrine is the drug of choice 0. The stingers should be removed without squeezing them. Black widow spiders have a characteristic a red hourglass on the belly.
Bitten patients experience nausea, vomiting, and severe generalized muscle cramps. The antidote is IV calcium gluconate. Muscle relaxants also help. Brown recluse spider bites are often not recognized at the time of the bite. In the next several days, a skin ulcer develops, with a necrotic center and a surrounding halo of erythema. Surgical debridement of all necrotic tissue is needed.
Skin grafting may be needed subsequently. Human bites are bacteriologically the dirtiest bite one can get. They require extensive irrigation and debridement in the OR and antibiotics. A classic human bite is the sharp cut over the knuckles on someone who punched someone else in the mouth and was cut by the teeth of the victim. They often show up in the ED with a cover story, but should be recognized because they need specialized orthopedic care.
Hip pathology in older children may present as hip or knee pain. Legg-Calve- Perthes disease is avascular necrosis of the capital femoral epiphysis and occurs around age 6, with insidious development of limping, decreased hip motion, and hip or knee pain.
Diagnosis is confirmed by AP and lateral hip x-rays. Treatment is controversial, usually containing the femoral head within the acetabulum by casting and crutches. Slipped capital femoral epiphysis SCFE is the most common hip disorder in adolescents. It is an orthopedic emergency because further slippage may compromise the blood supply and result in avascular necrosis of the femoral head.
The typical patient is an overweight boy around age 13 who complains of groin or knee pain, and who ambulates with a limp. When sitting with the legs dangling, the sole of the foot on the affected side points toward the other foot.
On physical exam there is limited hip motion, and as the hip is flexed the thigh goes into external rotation and cannot be rotated internally. X-rays are diagnostic, and surgical treatment relies on placement of pins to hold the femoral head back in place. A septic hip is an orthopedic emergency.
It is seen in toddlers who have had a febrile illness, and then refuse to move the hip. They hold the leg with the hip flexed, in slight abduction and external rotation, and appear uncomfortable with passive movement of the joint e. White blood cell count and erythrocyte sedimentation rate are elevated. Diagnosis is made by aspiration of the hip under general anesthesia, and surgical irrigation and open drainage are performed if pus is obtained. Acute hematogenous osteomyelitis is seen in small children who have had a febrile illness and presents as severe localized pain in a bone with no history of trauma to that bone.
X-rays will not show anything for several weeks. MRI reveals prompt diagnosis. Treatment is IV antibiotics. Genu varum bow-legs is normal up to age 3; no treatment is needed. Genu valgus knock-knee is normal between ages 4—8; no treatment is needed. Osgood-Schlatter disease osteochondrosis of the tibial tubercle is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps. Physical exam shows localized pain right over the tibial tubercle in the absence of knee swelling.
Treatment is initially with rest, ice, compression, and elevation. If conservative management fails, treatment is immobilization of the knee in an extension or cylinder cast for 4—6 weeks. Club foot talipes equinovarus is seen at birth. Both feet are turned inward, and there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia. The most sensitive screening finding is to look at the girl from behind while she bends forward.
In addition to the cosmetic deformity, severe cases develop decreased pulmonary function. Bracing is used to arrest progression; severe cases may require surgery. Early treatment is mandated. Also, the healing process is much faster than in the adult. The only areas where children have special problems include supracondylar fractures of the humerus and fractures of any bone that involve the growth plate or epiphysis.
Supracondylar fractures of the humerus occur with hyperextension of the elbow in a child who falls on the hand with the arm extended. The injuries are particularly dangerous due to the proximity of the brachial artery and ulnar nerve. Although these fractures are treated with standard casting or traction and rarely need surgery, they require careful monitoring of vascular and nerve integrity and vigilance regarding development of compartment syndrome. Supracondylar Fracture of the Humerus Fractures that involve the growth plate or epiphysis can be treated by closed reduction if the epiphysis and growth plate are displaced laterally from the metaphysis but they are in one piece i.
If the growth plate is fractured into two pieces, open reduction and internal fixation will be required to ensure precise alignment and even growth to avoid chronic deformity of the extremity.
The Salter Harris SH classification is commonly used to grade epiphyseal fractures. Clavicular fracture is typically at the junction of middle and distal thirds. It is treated by placing the arm in a sling. Figure-of-8 bandage treatment is now less popular.
Anterior dislocation of the shoulder is by far the most common shoulder dislocation. Patients hold the arm close to their body but rotated outward as if they were going to shake hands. There may be numbness in a small area over the deltoid, from stretching of the axillary nerve.
AP and lateral x-rays are diagnostic. Some patients develop recurrent dislocations with minimal trauma. Posterior shoulder dislocation is rare and occurs after massive uncoordinated muscle contractions, such as epileptic seizure or electrical burn.
The arm is held in the usual protective position close to the body, internally rotated. Regular x- rays can easily miss it; axillary views or scapular lateral views are needed. Treatment is with close reduction and long arm cast. Monteggia fracture results from a direct blow to the ulna i. There is diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head.
Galeazzi fracture is the mirror image: In both of these, the broken bone often requires open reduction and internal fixation, whereas the dislocated one is typically handled with closed reduction. Fracture of the scaphoid carpal navicular affects a young adult who falls on an outstretched hand. Chief complaint is typically wrist pain, with physical exam revealing localized tenderness to palpation over the anatomic snuff box.
In undisplaced fractures, x-rays are usually negative, but thumb spica cast is indicated just with the history and physical findings. X-rays will show the fracture 3 weeks later. If original x-rays show displaced and angulated fracture, open reduction and internal fixation are needed. Scaphoid fractures are notorious for a very high rate of nonunion secondary to avascular necrosis. Metacarpal neck fracture typically the fourth or fifth, or both happens when a closed fist hits a hard surface like a wall.
The hand is swollen and tender, and x-rays are diagnostic. Treatment depends on the degree of angulation, displacement, or rotary malalignment: Hip fracture is a bit of a misnomer for fractures that involve the proximal femur. These fractures typically occur in the elderly following a fall. Specific treatment depends on the specific location as shown by x-rays.
Femoral neck fracture, particularly if displaced, compromises the very tenuous blood supply of the femoral head. Faster healing and earlier mobilization can be achieved by replacing the femoral head with a prosthesis. Right Femoral Neck Fracture on X-ray Intertrochanteric fracture is less likely to lead to avascular necrosis and is usually treated with open reduction and pinning. The unavoidable immobilization that ensues poses a very high risk for deep venous thrombosis and pulmonary emboli, thus post-op anticoagulation is recommended.
Femoral shaft fracture is common and often requires operative management in adults with intramedullary rod fixation. If bilateral and comminuted, it may produce enough internal blood loss to lead to shock external fixation may help while the patient is stabilized. If open, it is an orthopedic emergency, requiring OR irrigation and closure within 6 hours. If multiple, fat embolism syndrome may develop, in which severe respiratory distress occurs secondary to marrow fat entering the blood stream and embolizing to the pulmonary vasculature.
Treatment is supportive care. Knee injury typically produces swelling of the knee; knee pain without swelling is unlikely to be a serious knee injury.
Collateral ligament injury is usually sustained when the force of impact at the side of the knee, a common sports injury. Medial forces to the knee generally result in disruption of the lateral ligament and vice versa. The knee will be swollen and there is localized pain by direct palpation on the affected side. Abduction demonstrates the medial injuries valgus stress test , whereas adduction diagnoses the lateral injuries varus stress test.
Isolated injuries are treated with a hinged cast. When several ligaments are torn, surgical repair is preferred. Anterior cruciate ligament ACL injury is more common than posterior injury. There is severe knee swelling and pain. Posterior cruciate ligament PCL injury produces the opposite findings. MRI is diagnostic. Sedentary patients may be treated with immobilization and rehabilitation, whereas athletes require arthroscopic reconstruction.
Meniscal tear is difficult to diagnose clinically and on x-rays, but is beautifully demonstrated on MRI.
There is tenderness to palpation over a very specific point on the bone, but x-rays are initially normal. Treat with a cast, and repeat the x-rays in 2 weeks.
Non—weight bearing with crutches is another option. Leg fracture involving the tibia and fibula is often seen when a pedestrian is hit by a car. Physical exam shows angulation; x-rays are diagnostic. Casting takes care of the ones that are easily reduced; intramedullary nailing is needed for the ones that cannot be aligned.
The lower leg along with the forearm is one of the most common locations for development of the compartment syndrome. Increasing pain after a long leg cast has been applied always requires immediate removal of the cast and appropriate assessment.
Because of the superficial location of the tibia, many significant tibial fractures are open fractures. Rupture of the Achilles tendon is often seen in middle-aged recreational athletes who subject themselves to severe strain tennis, for instance. As they plant the foot and change direction, a loud popping noise is heard like a rifle shot , and they fall clutching the ankle. Limited plantarflexion is still possible; but pain, swelling, and limping bring them to seek medical attention.
Casting in equinus position allows healing over several months; surgery achieves a quicker cure. Fracture of the ankle occurs when falling on an inverted or everted foot. In either case, both malleoli break. AP, lateral, and mortise x-rays are diagnostic. Open reduction and internal fixation are needed if the fragments are displaced. It occurs most frequently in the forearm or lower leg.
Precipitating events include prolonged ischemia followed by reperfusion, crushing injuries, or other types of trauma. The patient has pain and limited use of the extremity; palpation of soft tissue within the compartment feels very tight and tender to palpation.
The most reliable physical finding is excruciating pain with passive extension. Emergency fasciotomy is required for treatment. Pain under a cast is always handled by removing the cast and examining the limb. Open fracture, in which a broken bone protrudes from the wound, requires irrigation in the OR and suitable reduction within 6 hours from the time of the injury. It is also called compound fracture. Posterior dislocation of the hip occurs when the femur is driven backward, such as in a head-on car collision where the knees hit the dashboard.
Because of the tenuous blood supply of the femoral head, emergency reduction is needed to avoid avascular necrosis. In about 3 days the patient is extremely sick, looking toxic and moribund. The affected site is tender, swollen, discolored, and has gas crepitation. Treatment includes IV penicillin, extensive emergency surgical debridement, and possibly hyperbaric oxygen.
Gangrene of the Toes phil. If a patient comes in unable to dorsiflex extend the wrist, and regains function when the fracture is reduced and the arm is placed on a hanging cast or coaptation sling, no surgical exploration is needed. However, if nerve paralysis develops or remains after reduction, the nerve is entrapped and surgery has to be done.
Popliteal artery injury can occur in posterior dislocations of the knee. Delayed restoration of flow may require a prophylactic fasciotomy. Injury patterns—the second hidden fracture The direction of force that produces an obvious injury may produce another one that is less obvious and needs to be sought.
Falls from a height landing on the feet may have obvious foot or leg fractures, but fractures of the lumbar or thoracic spine may be less obvious and must be assessed. Head-on automobile collisions may produce obvious injuries in the face, head, and torso, but if the knees hit the dashboard, the femoral heads may be driven backward into the pelvis or out of the acetabulum and thus cause a fracture or dislocation.
The presence of facial fractures or closed head injuries mandates evaluation of the cervical spine initially with CT scan and further with MRI if pain or neurological symptoms persist. The diagnosis is clinical, but the American Academy of Orthopaedic Surgery recommends that wrist x-rays including carpal tunnel view be done to rule out other pathology.
Initial treatment is splinting and anti-inflammatory agents. If these conservative measures fail, surgery is indicated following electromyography and nerve conduction velocity. De Quervain tenosynovitis is more common in women and is often seen after pregnancy. Repetitive activities with the thumb in extension and abduction pinching, grasping result in irritation and inflammation of the thumb extensor tendons.
Patients complain of pain along the radial side of the wrist and the first dorsal compartment. On physical exam the pain can be reproduced by asking her to hold the thumb inside her closed fist, then forcing the wrist into ulnar deviation. Splint and anti-inflammatory agents can help, but steroid injection is most effective. Surgery is rarely needed. Dupuytren contracture occurs in older men of Norwegian ancestry and in alcoholics.
There is contracture of the palm of the hand, and palmar fascial nodules can be felt.
Surgery may be needed when the hand can no longer be placed flat on a table. A felon is an abscess in the pulp of a fingertip, often secondary to a neglected penetrating injury.
Patients complain of throbbing pain and have all the classic findings of an abscess, including fever. Because the pulp is a closed space with multiple fascial trabecula, pressure can build up and lead to tissue necrosis; thus surgical drainage is urgently indicated but care should be taken to avoid the flexor tendon sheath.
On physical exam there is collateral laxity at the thumb-metacarpophalangeal joint, and if untreated it can be dysfunctional and painful, and lead to arthritis.
Casting is usually effective. Jersey finger is an avulsion injury to the flexor digitorum profundus tendon sustained when the flexed finger is forcefully extended as in someone unsuccessfully grabbing a running person by the jersey.
When making a fist, the distal phalanx of the injured finger does not flex with the others. Mallet finger is the opposite: The tip of the affected finger remains flexed when the hand is extended, resembling a mallet. For both of these injuries, splinting is usually the first line of treatment.
Traumatically amputated digits are surgically reattached whenever possible. The amputated digit should be cleaned with sterile saline, wrapped in a saline- moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice. The digit should not be placed in antiseptic solutions or alcohol, should not be put on dry ice, and should not be allowed to freeze. Peak age incidence is the fourth decade of life. Patients cannot ambulate and they hold the affected leg flexed.
Straight leg-raising test reproduces excruciating pain and MRI confirms the diagnosis. Treatment for most patients is bed rest, physical therapy, and pain control, enhanced by a regional nerve block; surgical intervention is needed if neurologic deficits are progressing; emergency intervention is needed in the presence of the cauda equine syndrome distended bladder, flaccid rectal sphincter, or perineal saddle anesthesia.
Ankylosing spondylitis is seen in men in the third and fourth decades of life who complain of chronic back pain and morning stiffness. The pain is worse at rest and improves with activity. Many of these patients have the HLA B antigen, which is also associated with uveitis and inflammatory bowel disease. Metastatic malignancy should be suspected in the elderly who have progressive back pain that is worse at night and unrelieved by rest or positional changes.
Weight loss is often an additional finding. The most common pathology is lytic breast cancer metastases in women and blastic prostate metastases in men. Most lesions are identifiable on x-ray, but MRI is a more sensitive diagnostic tool. It starts because of the neuropathy and does not heal because of the microvascular disease.
It can sometimes heal with good blood glucose control and wound care, but often become chronic and sometimes leads to amputation due to osteomyelitis. Ulcer from arterial insufficiency is usually as far away from the heart as it can be, i.
It looks dirty, with a pale base devoid of granulation tissue. The patient has other manifestations of arteriosclerotic occlusive disease absent pulses, trophic changes, claudication, or rest pain.
Workup begins with Doppler studies looking for a pressure gradient, though in the presence of microvascular disease this may not be present and these lesions are less amenable to surgical therapy. Venous stasis ulcer develops in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus. The ulcer is painless, with a granulating bed. The patient has varicose veins and suffers from frequent bouts of cellulitis.
Duplex scan is useful in the workup. Treatment revolves around physical support to keep the veins empty: Surgery may be required vein stripping, grafting of the ulcer, injection sclerotherapy ; endovascular ablation with laser or radiofrequency may also be used. Venous Stasis Ulcers wikipedia. The classic setting is one of many years of healing and breaking down, such as seen in untreated third-degree burns that underwent spontaneous healing, or in chronic draining sinuses secondary to osteomyelitis.
Biopsy is diagnostic. Treatment is wide local excision and skin grafting if necessary. FOOT PAIN Plantar fasciitis is a very common but poorly understood problem affecting older, overweight patients who complain of disabling, sharp pain on the sole of the foot or heel every time the foot contacts the ground.
The pain is worse in the mornings. X-rays show a bony spur matching the location of the pain, and physical exam shows exquisite tenderness to palpation over the spur, although the bony spur is not likely the cause of the problem as many asymptomatic people have similar spurs.
Spontaneous resolution occurs over several months, during which time symptomatic treatment is offered. The neuroma is palpable and exquisitely tender to palpation. The cause is typically the use of pointed, high heel shoes or pointed cowboy boots that force the toes to be bunched together. Management includes analgesics and more sensible shoes, but surgical excision can be performed if conservative management fails.
Gout typically produces swelling, redness, and exquisite pain of sudden onset at the first metatarsal-phalangeal joint in middle-aged obese men with high serum uric acid. Uric acid crystals are identified in fluid from the joint. Treatment for the acute attack is indomethacin and colchicine; treatment for chronic control is allopurinol and probenecid. They present with persistent low-grade pain for several months. Osteogenic sarcoma is the most common primary malignant bone tumor.
It is seen in ages 10—25, usually around the knee lower femur or upper tibia. Ewing sarcoma is the second most common. It affects younger children ages 5—15 and it grows in the diaphyses of long bones. ADULTS Most malignant bone tumors in adults are metastatic, from the breast in women lytic lesions and from the prostate in men blastic lesions.
Localized pain is an early finding. Lytic lesions commonly present as pathologic fractures. Multiple myeloma is seen in old men and presents with fatigue, anemia, and localized pain at specific places on several bones. X-rays are diagnostic, showing multiple, punched-out lytic lesions. They also have Bence-Jones protein in the urine and abnormal immunoglobulins in the blood, best demonstrated by serum protein electrophoresis SPEP.
Treatment is chemotherapy; thalidomide can be used in the event that chemotherapy fails. Soft tissue sarcoma has relentless growth of soft tissue mass over several months.
It is firm and typically fixed to surrounding structures. It can metastasize hematogenously to the lungs but does not invade the lymphatic system. MRI delineates the extent of the mass and invasion of local structures. Incisional biopsy to obtain tissue is diagnostic. Treatment includes wide local excision, radiation, and chemotherapy. NOTE Do not memorize the specific percentages with respect to cardiac complications. Just get an idea of what contributes to cardiac risk. Jugular venous distention, which indicates the presence of CHF, is the worst single finding predicting high cardiac risk.
If at all possible, treatment with ACE inhibitors, beta-blockers, digitalis, and diuretics should precede surgery. Recent MI is the next worse predictor of cardiac complications. Therefore delaying surgery longer than 6 months from MI is the best course of action. If surgery cannot be safely delayed, admission to the ICU before surgery is recommended to optimize cardiac performance. The smoking history, or the presence of chronic obstructive pulmonary disease COPD , should lead to evaluation.
Start with pulmonary function tests, and, if abnormal, obtain an arterial blood gas. Cessation of smoking for 8 weeks and intensive respiratory therapy physical therapy, expectorants, incentive spirometry, humidified air should precede surgery.
Predict surgical mortality as follows: Severe nutritional depletion is identified by one or more of the following: Surprisingly, as few as 4—5 days of preoperative nutritional support preferably via the gut can make a big difference, and 7—10 days would be optimal if the surgery can be deferred for that long.
Rehydration, return of urinary output, and at least partial correction of the acidosis and hyperglycemia must be achieved before surgery. A family history may exist. Monitor post-operatively for the development of myoglobinuria. Bacteremia is seen within 30—45 minutes of invasive procedures instrumentation of the urinary tract is a classic example and presents as chills and a temperature spike as high as 40 C F.
Draw multiple sets of blood cultures and start empiric antibiotics. Although rare, severe wound pain and very high fever within hours of surgery should alert you to the possibility of gas gangrene in the surgical wound.
Immediately remove surgical dressings and examine the wound. Gas gangrene is not subtle, and should prompt immediate return to the OR for wound reopening and washout. Postoperative fever Assess the risk for the other causes listed above, listen to the lungs, do a chest x- ray, improve ventilation deep breathing and coughing, postural drainage, incentive spirometry , and perform a bronchoscopy if necessary.
Pneumonia will happen in about 3 days if atelectasis is not resolved. Fever will persist, leukocytosis will be present, there may be purulent sputum, and chest x- ray will demonstrate an infiltrate s. Obtain sputum cultures and treat with appropriate antibiotics. UTI typically produces fever starting on post-operative day 3. Work up with a urinalysis and urinary cultures and treat with appropriate antibiotics. Deep vein thrombophlebitis typically produces fever starting around post- operative day 5.
Diagnosis requires a high index of suspicion. Treatment is systemic anticoagulation initially with heparin or unfractionated low molecular weight heparin and transitioned to a long term anticoagulant, typically warfarin. Wound infection typically begins to produce fever around post-operative day 7. Physical exam will reveal erythema, warmth, tenderness, and fluctuance. If only cellulitis is present treat with antibiotics. CT scan of the appropriate ry body cavity is diagnostic.
Percutaneous image-guided drainage is therapeutic. When it happens post- operatively, it is typically within the first 2—3 days, presenting as chest pain in one-third of patients and with the complications of the MI in the rest. The most et reliable diagnostic test is serum troponin-I levels. Treatment is directed at ok the complications. Thrombolysis cannot be used in the peri-operative setting, but emergency angioplasty and coronary stenting can be life-saving.
The pain is pleuritic, sudden onset, and is accompanied by shortness of breath. The patient is anxious, diaphoretic, and tachycardic, with prominent distended veins in the neck and forehead a low CVP virtually excludes the diagnosis. Arterial blood gases demonstrate et hypoxemia and often hypocapnia. Diagnosis is with CT angiogram, which is a.
Sequential compression ht devices should be used on anyone who does not have a lower extremity fracture or significant lower extremity arterial insufficiency. Prevention includes strict restriction of oral intake prior to surgery and antacids before induction. Therapy starts with bronchoscopic lavage and removal of acid et and particulate matter followed by bronchodilators and respiratory support. Antibiotics are ok only indicated if a patient demonstrates evidence of the resultant pneumonia, i.
If the abdomen is open, quick decompression can be achieved through the diaphragm but this is not recommended. A better: Formal chest tube has to be placed following acute decompression.
Sepsis is another prime cause. Check arterial blood gases and provide respiratory support if airway protection is threatened. Adult respiratory distress syndrome ARDS is seen in patients with a et complicated post-op course, often complicated by sepsis as the precipitating. There are bilateral pulmonary infiltrates and hypoxia, with no evidence of ok CHF. The centerpiece of therapy is positive end-expiratory pressure PEEP with low volume ventilation as excessive ventilatory volumes have been bo demonstrated to result in barotrauma.
A source of sepsis must be sought and ry corrected. IV benzodiazepines are the standard therapy, but oral alcohol is available at most hospitals for this: This can be inadvertently induced by the liberal administration of sodium-free IV fluids like D5W in a postoperative patient with high levels of antidiuretic hormone ADH; triggered by the response to trauma. Therapy, which includes hypertonic saline and osmotic diuretics, is controversial.
Unfortunately mortality is high, especially in young women; the best management is prevention by including sodium in IV fluids. Surgical damage to the posterior pituitary with unrecognized diabetes insipidus is a good example. Unrecognized osmotic diuresis can also do it.
Ammonium intoxication is a common source of coma in the cirrhotic patient. The patient feels the need to void, but cannot do it. Bladder catheterization should be performed hours post-operatively if no spontaneous voiding has occurred. Indwelling Foley catheter placement is indicated at the second some say third et consecutive catheterization. Look for a plugged or kinked catheter, and flush the tubing to bo dislodge any clot that may have formed. Dehydrated patients will respond with a temporary increase in urinary output, whereas those in renal failure will not ht do so.
A more scientific test is to measure urinary sodium: An even more scientific test is to calculate the fractional excretion of sodium, or FeNa. In order to calculate the FeNa, plasma and urinary sodium and creatinine must be measured. Bowel sounds are absent or hypoactive and there is no passage of gas. There may be mild distension, but there is no pain.
Paralytic ileus is prolonged by hypokalemia. What was probably assumed to be paralytic ileus not ok resolving after days is most likely an early mechanical bowel obstruction.
X- rays will show dilated loops of small bowel and air-fluid levels. Diagnosis is bo confirmed with an abdominal CT scan that demonstrates a transition point ry between proximal dilated bowel and distal collapsed bowel at the site of the obstruction.
Surgical intervention is needed to correct the problem. Patients develop abdominal distention without tenderness, and x-rays show a massively dilated colon. After fluid and electrolyte correction, it is imperative that mechanical obstruction be ruled out radiologically or by endoscopy, before giving IV neostigmine to restore colonic motility. A long rectal tube is also commonly used. Wound dehiscence is typically seen around post-operative day 5 after open laparotomy. It typically happens bo when the patient who may not have been recognized as having a dehiscence ry coughs, strains, or gets out of bed.
The patient must be kept in bed, and the bowel covered with large sterile dressings soaked with warm saline.
Emergency ge abdominal closure is required. It may harm the patient in a number of ways. If it drains freely, sepsis is not encountered patient is typically afebrile with no signs of peritoneal irritation though there are 3 other potential problems: Fluid and electrolyte loss Nutritional depletion Erosion and digestion of the abdominal wall http: Nature will do so if.
Foreign body bo Radiation injury ry Infection or inflammatory bowel disease Epithelialization ge Neoplasm ur Distal obstruction Steroid use: The condition results in water loss from cells and typically presents as alterations in neurologic function. The extent of brain dysfunction depends on the magnitude and time et frame over which the hypernatremia developed.
This is ge achieved by using NS rather than D5W. In one scenario, a patient who starts with normal fluid volume adds to it by retaining water because of the presence of inappropriate amounts of ADH e. In slowly developing hyponatremia from inappropriate ADH, the brain has time to adapt, and therapy should be water restriction.
In the case of the hypovolemic, dehydrated patient losing GI fluids and forced et to retain water, volume restoration with isotonic fluids NS or lactated. Hypokalemia develops very ur rapidly over hours when potassium moves into the cells, most notably when diabetic ketoacidosis is corrected.
Therapy is obviously potassium replacement. The latter provides the quickest protection. Metabolic acidosis can occur from any of the following: Excessive production of fixed acids diabetic ketoacidosis, lactic acidosis, low-flow states Loss of buffers loss of bicarbonate-rich fluids from the GI tract Inability of the kidney to eliminate fixed acids renal failure et.
Metabolic alkalosis occurs classically in a setting involving loss of acid gastric fluid, for example with prolonged emesis or NG suction. Treatment involves replacement of chloride and potassium, thereby allowing the kidneys to correct the problem. Metabolic alkalosis can also develop if excess bicarbonate is administered. They are recognized by abnormal PCO2 low in alkalosis, high in acidosis in conjunction with the abnormal pH of the blood.
Therapy must be directed at correction of the underlying respiratory problem. For example, acute metabolic acidosis will result in tachypnea with lowering of pCO2 to mitigate the decrease in pH arising from the primary derangement in this case, metabolic et acid. When the diagnosis is uncertain, pH monitoring can be helpul to establish the presence of reflux and its correlation with the symptoms.
In that setting, endoscopy and biopsy are the indicated tests,: Appropriate in long-standing symptomatic disease that cannot be controlled by medical means using laparoscopic Nissen fundoplication Necessary when complications have developed ulceration, stenosis using laparoscopic Nissen fundoplication Imperative if there are severe dysplastic changes resection is needed http: Manometry studies are used for the definitive diagnosis.
Barium swallow is typically done first to evaluate for an obstructing lesion. Achalasia is seen more commonly in women. There is dysphagia that is worse for liquids; the patient eventually learns that sitting up straight and waiting allows the weight of the column of liquid to overcome the sphincter.
There is et occasional regurgitation of undigested food. X-rays show megaesophagus.
The most appealing current treatment is balloon ok dilatation done by endoscopy; however, recurrence is high and many patients ultimately require an esophagomyotomy Heller. Significant weight loss is always seen.
Squamous cell ur carcinoma is seen in men with a history of smoking and drinking. Diagnosis is established by endoscopy and: Mallory-Weiss tear is a mucosal laceration at the junction of the esophagus and stomach. It occurs after prolonged, forceful vomiting and presents with bright red hematemesis. Endoscopy establishes diagnosis, and allows treatment with endoscopic clipping or coagulation. There is continuous, severe, wrenching epigastric and low sternal pain of sudden onset, soon followed by fever, leukocytosis, and a very sick-looking patient.
Contrast swallow with a water- soluble agent Gastrografin is diagnostic and emergency surgical repair should follow. Delay in diagnosis and treatment has grave consequences due to the morbidity of mediastinitis. Instrumental perforation of the esophagus is by far the most common reason for esophageal perforation. Shortly after completion of endoscopy, symptoms as et described above will develop. There may be emphysema in the lower neck.
Contrast studies and prompt repair are ok imperative. Stomach Gastric adenocarcinoma is more common in the elderly. Symptoms include: Anorexia et Weight loss. CT scan helps assess operability. Surgery is the best therapy.
Presentation and diagnosis are similar, but treatment is chemotherapy. There is colicky abdominal pain and protracted vomiting, progressive abdominal distention if it is a low obstruction ,. Early on, high-pitched bowel sounds coincide ok with the colicky pain after a few days there is silence.
X-rays show distended bo loops of small bowel, with air-fluid levels. Treatment starts with NPO, NG suction, and IV fluids, hoping for spontaneous resolution, while watching for ry early signs of strangulation or peritonitis. Surgery is done if conservative ge management is unsuccessful, within 24 hours in cases of complete obstruction or within a few days in cases of partial obstruction. It starts as described above, but eventually the patient: Emergency surgery is required.
Mechanical intestinal obstruction caused by an incarcerated inguinal hernia has the same clinical picture and potential for strangulation as described above, but the physical exam shows the irreducible hernia that used to be reducible. Because we can effectively eliminate the hernia we cannot effectively eliminate adhesions , all of these undergo surgical repair, but the timing varies: Carcinoid syndrome is seen in patients with a small bowel carcinoid tumor with liver metastases.
It includes diarrhea, flushing of the face, wheezing, and right- sided heart valvular damage look for prominent jugular venous pulse. Diagnosis is made with hour urinary collection for 5-hydroxyindolacetic acid 5-HIAA. A blood sample taken afterward will be normal. Thus, a hour urinary collection is more likely to provide the diagnosis.
Acute appendicitis is one of the most common gastrointestinal conditions that requires emergency surgery. Clinical presentation provides important diagnostic et clues. The classic picture of acute appendicitis begins with anorexia, followed.
CT scan has become the standard diagnostic modality for those cases. Colon Cancer of the right colon typically presents with anemia hypochromic, iron deficiency in the right age group age 50— Colonoscopy and biopsies are diagnostic; surgery right hemicolectomy is treatment of choice.
Cancer of the left colon typically presents with bloody bowel movements and obstruction. Blood coats the outside of the stool, there may be constipation, stools may have narrow caliber. Flexible proctosigmoidoscopic exam 45 or 60 cm and biopsies are usually the first diagnostic study. Before surgery is done, full colonoscopy is needed to rule out a synchronous second primary lesion more proximally. CT scan helps assess operability and extent. Treatment is elective et surgical resection sigmoidectomy or L-colectomy and primary anastomosis for.
Polyps that are not premalignant include juvenile, Peutz-Jeghers, isolated ur inflammatory, and hyperplastic. Definitive surgical treatment of CUC requires removal of affected colon, including all of the rectal mucosa which is always involved. Clostridium difficile associated disease CDAD or psuedomembranous http: Any antibiotic can do it. Clindamycin was the first one described, and, currently, Cephalosporins are the most common cause.
There is profuse, watery diarrhea, crampy abdominal pain, fever, and leukocytosis. Diagnosis is best made by identifying the toxin in the stool. Stool cultures take too long, and the pseudomembranes are not always seen on endoscopy. The culpable antibiotic should be discontinued, and no antidiarrheals should be used.
Metronidazole is the treatment of choice oral or IV , with vancomycin oral an alternative. Hemorrhoids typically bleed when they are internal can be treated with rubber et band ligation , or hurt when they are external may need surgery if conservative.
Internal hemorrhoids can become painful and produce itching if ok they are prolapsed. There is exquisite pain with defecation ry and blood streaks covering the stools. The fear of pain is so intense that patients avoid bowel movements and get constipated and may even refuse proper ge physical examination of the area. Examination may need to be done under ur anesthesia the fissure is usually posterior, in the midline.
A fistula, if present, could be drained with setons while medical therapy is underway. Remicade helps healing. Ischiorectal abscess perirectal abscess is very common. The patient is febrile, with exquisite perirectal pain that does not let him sit down or have bowel movements. Physical exam shows all the classic findings of an abscess rubor, dolor, calor, and fluctuance lateral to the anus, between the rectum and the ischial tuberosity.
Incision and drainage are needed, and cancer should be ruled out by proper examination during the procedure. If patient is a poorly-controlled et diabetic, necrotizing soft tissue infection may follow; significant monitoring is. Epithelial migration from the anal crypts where the abscess originated ry and from the perineal skin where the drainage was done form a permanent tract.
Patient reports fecal soiling and occasional perineal discomfort. Physical ge exam shows an opening or openings lateral to the anus, a cordlike tract may be ur felt, and discharge may be expressed. Rule out a necrotic and draining tumor, and treat with fistulotomy. A fungating mass grows out of ht the anus, metastatic inguinal nodes are often palpable. Diagnose with biopsy. Treatment starts with the Nigro chemoradiation protocol 5-fluorouracil, mitomycin, and external beam radiation , followed by surgery if there is residual tumor.
GI bleeding arising from the colon comes from angiodysplasia, polyps, diverticulosis, or cancer, all of which are diseases of older people. Even hemorrhoids become et more common with age. The same is true when blood is recovered by an NG tube in a patient who presents with bleeding: The best next diagnostic test in that setting is upper GI endoscopy. Be sure to look at the mouth and nose first.
Start the workup with upper GI endoscopy. Red blood per rectum could come from anywhere in the GI tract including upper GI, as it may have transited too fast to be digested. The first diagnostic http: If blood is retrieved, an upper source has been established follow with upper endoscopy as above.
If no blood is retrieved and the fluid is white no bile , the territory from the tip of the nose to the pylorus has been excluded, but the duodenum is still a potential source and upper GI endoscopy is still necessary. If no blood is recovered and the fluid is green bile tinged , the entire upper GI tip of the nose to ligament of Treitz has been excluded, and there is no need for an upper GI endoscopy.
Bleeding hemorrhoids should always be excluded first by ok physical exam and anoscopy. Colonoscopy is not helpful during an active bleed as blood obscures the field. Once hemorrhoids have been excluded, management bo is based on the rate of bleeding. If the bleeding is slower, i. The difficulty with the tagged red-cell study is that it is a slow test, and by the time it is finished, the patient is often no longer bleeding and the subsequent angiogram is useless.
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