Академический Документы
Профессиональный Документы
Культура Документы
http://jacknaimsnotes.blogspot.com/2010/02/surgery-osce-quiz-5.html
A 67 Years Old Malay Lady with past medical history of pulmonary tuberculosis and has
completed treatment currently presented with fever for 3/7. It is a high grade fever associated
with chills but no rigor. The fever is temporarily relieved by tab. Paracetamol. There is no
pleuritic chest pain, haemoptysis, shortness of breath, night sweat and no symptoms of urinary
tract infection.
Two days later, she develops Right iliac fossa pain that brought her to hospital. It is pricking in
nature, continuous, increase in frequency when coughing and not radiate to any part of body. It
is also associated with anorexia and nausea.
After a thorough examination, she was prep for surgery and organ x was removed.
Below is the picture of organ X
Questions
1)
2)
3)
4)
5)
8) Management
a) Resuscitation and acute management of the patient
i. Monitor the vital sign
ii. Get an IV access
iii. Keep nil by mouth
iv. Fluid therapy 3 pints (2 pints normal saline and 1 pints dextrose 5%)
v. Urinary catheter to observe fluid output (normally 0.5 cc/kg/ hour in well
hydrated adult)
vi. Pain killer, IM pethidine 50 mg stat
vii. IV Pentaprazole
viii. Thorough fever work up (blood culture and sensitivity, urine FEME, urine culture
and sensitivity)
ix. Empirical antibiotic covering enteric bacteria.
b) Establishing diagnosis
i. Mostly, diagnosis is made by clinical (history and examination) can use Alvarado
scoring for appendicitis. Therefore, other investigation is not needed.
ii. Full blood count may show Leukocytosis
iii. ESR may elevate.
iv. Ultrasound and contrast enhanced CT scan (if diagnosis is uncertain and if there
is high possibility of other causes than appendicitis is anticipated
c) Definitive treatment is Appendicectomy
i. Pre Op
- Stabilize the patient
- History taking to identify high risk patient.
- Keep nil by mouth
- Blood investigation (FBC, GSH, RFT, LFT)
ii. Intra Op
- Surgery under general anesthesia
- Cover un necessary part to avoid hypothermia
- Adequate skin prep
- Use gridiron or lanz incision
- Identify the appendix by locating the taenia coli.
- Take swab from perforated appendix for culture and sensitivity
- Peritoneal irrigation with 2 liters warm normal saline after removal of
perforated appendicitis and closure of removal site
- Drainage is not compulsory in view of complete peritoneal irrigation.
iii. Post Op
- Monitor the patient in the recovery area
- Keep nil by mouth
- Transfer the patient to ward once stable.
- Analgesic (IV Tramadol)
- IV Pantaprazole
- Continue antibiotic to cover gram negative and anaerob (Ciprobay and
flagyl) because the appendix has perforated.
- Daily checking of surgical wound and dressing if required.
- Allow discharge with tablet antibiotic and pain killer once patient
recovery is satisfactory.
Reference
1.
2.
3.
4.
Alastar M. Thompson, General Surgery Anatomy And Examination, Churchill Livingston, 2002
Danny O Jacobs, First Exposure General Surgery, Mc Graw Hill Company, 2007
Norman S. Williams, Christopher J.K. Bulstrode & R. Ronan OConnel, Bailey & Loves Short Practice
of Surgery 25th edition, Edward Arnold Publisher ltd, 2008
World Health Organization, Surgical Care at the District Hospital, WHO, 2003