NMS Surgery Casebook, 2e (Dec 17, 2010)_(160831586X)_(LWW).pdf 9781608315864, 2015010502

Table of contents :
NMS Surgery Casebook, Second Edition
Half-Title Page
Title Page
Copyright
Dedication
Preface
Contributors
Contents
Part I: General Issues
Chapter 1: Preoperative Care
Key Thoughts
Case 1.1: Routine Surgery in a Healthy Patient
◆ How would you assess the patient’s operative risk?
Table 1-1: Active Cardiac Conditions for Which the Patient Should UndergoEvaluation and Treatment Before Noncardiac Surgery (Class I, Level ofEvidence: B)
Table 1-2: Cardiac Risk* Stratifi cation for Noncardiac Surgical Procedures
Table 1-3: Estimated Energy Requirements for Various Activities
◆ What preoperative tests are necessary?
◆ How would you categorize the patient’s anesthesia risk?
Table 1-4: Preoperative Diagnosis-Based Investigations before Elective Surgery
◆ How would you decide whether to use local, spinal, or general anesthesia?
Table 1-5: American Society of Anesthesiologists’ Classifi cation ofPerioperative Mortality
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DeepTh oughts
For specifi c patients:
For specifi c planned procedures:
Case 1.2: Common Risk Factors Associated with Routine Surgery
◆ How would your preoperative assessment and proposed managementchange in each of the following situations?
Case Variation 1.2.1. The patient takes one aspirin per day.
Case Variation 1.2.2. The patient’s father and brother both died from acuteMIs at 45 years of age.
Case Variation 1.2.3. The patient’s most recent serum cholesterol is 320 mg/dL.
Case Variation 1.2.4. The patient’s preoperative ECG provides evidence of aprevious inferior MI, but he has no knowledge of this MI and is chest pain–freeon careful examination.
Case Variation 1.2.5. The patient has diabetes.
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Case Variation 1.2.6. The patient’s hematocrit is 34%, and his other laboratorytests are normal.
Case Variation 1.2.7. The patient’s hematocrit is 55%.
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Case Variation 1.2.8. The patient is obese (100 lb overweight) and reportsbecoming winded easily when climbing stairs.
Case 1.3: Common Problems in a Patient Waiting to Enter the Operating Room
◆ How would your proposed management change in each of the followingsituations?
Case Variation 1.3.1. The patient is known to be diabetic, and this morning hisblood glucose is 320 mg/dL.
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Case Variation 1.3.2. The patient has cellulitis from an infected hair follicle inhis axilla.
Case Variation 1.3.3. The patient experiences burning on urination.
Case Variation 1.3.4. His BP, which was 140/88 mm Hg in your offi ce, hasrisen to 180/110 mm Hg.
Case 1.4: Surgery in a Patient with Pulmonary Symptoms
◆ How would you interpret the following fi ndings, and how would they affectyour proposed management?
Case Variation 1.4.1. The patient has daily productive cough and has had thisfor many years. He smokes two packs per day.
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Case Variation 1.4.2. The patient normally has daily sputum production, buthis sputum has been green for 3 weeks.
Case Variation 1.4.3. The patient’s sputum has been blood-streaked for 3 weeks.
Case 1.5: Urgent Surgery in a Patient with Severe, Acute Pulmonary Function Problems
Case 1.6: Cardiac and Neurologic Risk Associated with Surgery for Peripheral Vascular Disease
Case 1.7: Surgery in a Patient with Liver Failure
Case 1.8: Surgery in a Patient with Chronic Kidney Problems
Case 1.9: Surgery in a Patient with Cardiac Valvular Disease
Case 1.10: Endocarditis Prophylaxis in a Surgical Patient with Valvular Heart Disease
Case 1.11: Surgery in a Patient with Cardiomyopathy
Chapter 2: Postoperative Care
Key Thoughts
Case 2.1: Postoperative Fluid and Electrolyte Management
Case 2.2: Postoperative Acute Renal Failure
Case 2.3: Postoperative Fever
Case 2.4: High Fever in the Immediate Postoperative Period
Case 2.5: Postoperative Cardiopulmonary Problems
Case 2.6: Management of a Small Bowel Fistula
Chapter 3: Wound Healing
Key Thoughts
Case 3.1: Wound Management and Complications
Case 3.2: Wound Infection
Case 3.3: Wound Classification Based on Risk of Subsequent Infection
Part II: Specific Disorders
Chapter 4: Thoracic and Cardiothoracic Disorders
Key Thoughts
Case 4.1: Asymptomatic Abnormality Seen on Chest Radiography
Case 4.2: Symptomatic Abnormality Seen on Chest Radiography
Case 4.3: Symptomatic Abnormality Located in the Hilum on Chest Radiography
Case 4.4: Lung Mass with Possible Metastases
Case 4.5: Symptomatic Superior Sulcus Tumor
Case 4.6: Hemoptysis and Atelectasis in a Young Patient
Case 4.7: New-Onset Pleural Effusion without Heart Failure
Case 4.8: Sudden Chest Pain and Shortness of Breath in a Young Patient
Case 4.9: Pleural-Based Chest Pain, Fever, and Pleural Effusion
Case 4.10: Progressively Increasing Substernal Chest Pain
Case 4.11: Mitral Valve Disease that Requires Surgery
Case 4.12: Aortic Valve Disease that Requires Surgery
Case 4.13: Congestive Heart Failure with Normal Coronary Arteries
ESOPHAGEAL DISEASE
Case 4.14: Recurrent Regurgitation of Undigested Food
Case 4.15: Dysphagia
Case 4.16: Dysphagia
Case 4.17: Dysphagia
Case 4.18: Muscular Weakness and a Mediastinal Mass
Chapter 5: Vascular Disorders
Key Thoughts
PERIPHERAL ARTERIAL DISEASE
Case 5.1: Brief Neurologic Event
Case 5.2: Other Transient Neurologic Events
Case 5.3: Asymptomatic Carotid Bruit
Case 5.4: Acute Vascular Event in the Leg
Case 5.5: Claudication
Case 5.6: Claudication and Absence of a Femoral Pulse
Case 5.7: Toe Ulceration in Peripheral Vascular Disease
Case 5.8: Aortoiliac Occlusive Disease
Case 5.9: Cardiac Risk in Major Vascular Reconstruction
Case 5.10: Pulsatile Mass in the Abdomen
Case 5.11: Ruptured Abdominal Aortic Aneurysm
Case 5.12: Complications of Abdominal Aortic Replacement
Case 5.13: Chronic Postprandial Abdominal Pain and Weight Loss
Case 5.14: Tearing Chest and Back Pain
VENOUS DISEASE
Case 5.15: Postoperative Leg Swelling
Case 5.16: Prevention of Deep Venous Thrombosis
Case 5.17: Postoperative Shortness of Breath
Case 5.18: Confounding Findings in Pulmonary Embolism
Case 5.19: Recurrent Pulmonary Embolism on Anticoagulation Therapy
Case 5.20: Gastrointestinal Bleeding as a Complication of Anticoagulation Therapy
Case 5.21: Severe Deep Venous Thrombosis
Chapter 6: Upper Gastrointestinal Tract Disorders
Key Thoughts
Case 6.1: Acute Epigastric Pain No. 1
Case 6.2: Acute Epigastric Pain No. 2
Case 6.3: Acute Epigastric Pain No. 3
Case 6.4: Acute Epigastric Pain No. 4
Case 6.5: Acute Epigastric Pain No. 5
Case 6.6: Acute Epigastric Pain No. 6
Case 6.7: Acute Epigastric Pain No. 7
Case 6.8: Upper Gastrointestinal Bleeding No. 1
Case 6.9: Upper Gastrointestinal Bleeding No. 2
Case 6.10: Acute Epigastric Pain No. 8
Chapter 7: Pancreatic and Hepatic Disorders
Key Thoughts
COMMON PANCREATICOBILIARY DISORDERS
Case 7.1: Asymptomatic Gallstones
Case 7.2: Right Upper Quadrant Pain No. 1
Case 7.3: Right Upper Quadrant Pain No. 2
Case 7.4: Right Upper Quadrant Pain No. 3
Case 7.5: Right Upper Quadrant Pain No. 4
Case 7.6: Right Upper Quadrant Pain No. 5
Case 7.7: Right Upper Quadrant Pain No. 6
Case 7.8: Right Upper Quadrant Pain No. 7
Case 7.9: Right Upper Quadrant Pain No. 8
Case 7.10: Complications of Laparoscopic Cholecystectomy
Case 7.11: Painless Jaundice
Case 7.12 : Painless Jaundice due to Obstruction at the Common Bile Duct Bifurcation
Case 7.13: Other Biliary Tract Cancers
Case 7.14: Acute Epigastric Pain No. 10
Case 7.15: Acute Epigastric Pain No. 11
Case 7.16: Acute Epigastric Pain No. 12
COMMON HEPATIC DISORDERS
Case 7.17: Hepatic Mass
Case 7.18: Fever and Pain in the Right Upper Quadrant
Chapter 8: Lower Gastrointestinal Disorders
Key Thoughts
SMALL INTESTINAL DISORDERS
Case 8.1: Crampy Abdominal Pain No. 1
Case 8.2: Crampy Abdominal Pain No. 2
Case 8.3: Crampy Abdominal Pain No. 3
Case 8.4: Injury to the Bowel during Lysis of Adhesions
Case 8.5: Crampy Abdominal Pain No. 4
Case 8.6: Abdominal Pain No. 5
Case 8.7: Abdominal Pain No. 6
INFLAMMATORY BOWEL DISEASE
Case 8.8: Abdominal Pain No. 7
Case 8.9: Perianal Disease in a Patient with Crohn Disease
Case 8.10: Management of Crohn Colitis
Case 8.11: Complications of Long-Standing Ulcerative Colitis
Case 8.12: Complications of Acute Colitis
DISORDERS OF THE COLON
Case 8.13: Right Lower Quadrant Pain No. 1
Case 8.14: Right Lower Quadrant Pain No. 2
Case 8.16: Right Lower Quadrant Pain No. 3
Case 8.17: Right Lower Quadrant Pain No. 4
Case 8.18: Right Lower Quadrant Pain No. 5
MALIGNANT DISORDERS OF THE COLON, RECTUM, AND ANUS
Case 8.19: Screening for Colorectal Cancer
Case 8.20: Heme-Positive Stool No. 1
Case 8.21: Heme-Positive Stool No. 2
Case 8.22: Heme-Positive Stool No. 3
Case 8.23: Heme-Positive Stool No. 4
Case 8.24: Operative Findings in Colon Cancer No. 1
Case 8.25: Complications of Postoperative Colectomy
Case 8.26: Heme-Positive Stool No. 5
Case 8.27: Heme-Positive Stool No. 6
Case 8.28: Metastasis in Colorectal Cancer
Case 8.29: Heme-Positive Stool No. 7
LOWER ABDOMINAL PAIN
Case 8.30: Left Lower Quadrant Pain No. 1
Case 8.31: Left Lower Quadrant Pain No. 2
Case 8.32: Left Lower Quadrant Pain No. 3
Case 8.33: Left Lower Quadrant Pain No. 4
LOWER GASTROINTESTINAL BLEEDING
Case 8.34: Massive Lower Gastrointestinal Bleeding
Case 8.35: Persistent Bleeding with a Massive Lower Gastrointestinal Bleed
OTHER BENIGN LOWER GASTROINTESTINAL TRACT DISORDERS
Case 8.36: Syndromes of Acute Colonic Dilation and Obstruction
Case 8.37: Rectal Prolapse
Case 8.38: Perianal Problems
Case 8.39: Colostomies
Chapter 9: Endocrine Disorders
Key Thoughts
Case 9.1: Thyroid Nodule Found on Examination
Case 9.2: Symptomatic Hypercalcemia
Case 9.3: Medical Management of Acute Hypercalcemia
Case 9.4: Secondary Hyperparathyroidism
Case 9.5: Hyperparathyroidism and Severe Hypertension in the Same Patient
Case 9.6: Acute Development of a Tender Neck Mass
Case 9.7: History of Hyperparathyroidism and Intractable Duodenal Ulcers
Case 9.8: Medullary Carcinoma of the Thyroid
Case 9.9: Incidentally Discovered Adrenal Mass
Chapter 10: Skin and Soft Tissue Disorders and Hernias
Key Thoughts
MALIGNANT MELANOMA
Case 10.1: Evaluation of a Skin Lesion
Case 10.2: Diagnosis of Malignant Melanoma in a Skin Lesion
Case 10.3: Malignant Melanoma with a Palpable Lymph Node
Case 10.4: Malignant Melanoma with Distant Metastasis
Case 10.5: Special Problems in Malignant Melanoma No. 1
Case 10.6: Special Problems in Malignant Melanoma No. 2
Case 10.7: Small Bowel Obstruction and History of Malignant Melanoma
SARCOMA
Case 10.8: Sarcoma of the Lower Extremity
Case 10.9: Metastatic Sarcoma to the Lung
HERNIAS AND RELATED CONDITIONS
Case 10.10: Pain in the Groin
Case 10.11: Inguinal Hernia
OPEN REPAIRS
LAPAROSCOPIC PROCEDURES
Case 10.12: Additional Hernia-Related Problems
Case 10.13: Ventral Hernia
Chapter 11: Breast Disorders
Key Thoughts
Case 11.1: Screening for Breast Cancer
Case 11.2: Evaluation of a Mammographic Abnormality
Case 11.3: Evaluation of Mammographic Microcalcifications
Case 11.4: Biopsy Results in Lesions Visible on Mammography
Case 11.5: Management of a Woman with a Palpable Breast Mass
Case 11.6: Management of a Woman with “Lumpy” Breasts
Case 11.7: Management of a Breast Mass in a Young Woman
Case 11.8: Management of a Woman with Nipple Discharge
Case 11.9: Staging and Prognosis in Infiltrating Ductal Carcinoma
Case 11.10: Some Clinical Factors that Affect Prognosis
Case 11.11: Management of a Woman with a Nipple Lesion
Case 11.12: Surgical Management of Breast Cancer
Case 11.13: Treatment Options for Stages I and II Breast Cancer
Case 11.14 : Breast Reconstruction
Case 11.15: Medical Management of Breast Cancer
Case 11.16: Treatment of Stages III and IV Breast Cancer
Case 11.17: Breast Mass with Cellulitis and Edema
Case 11.18: Events that Occur Later in Patients with Breast Cancer
Case 11.19: Breast Problems in Pregnancy and the Peripartum Period
Case 11.20: Breast Cancer in Patients of Advanced Age and Decreased Function
Case 11.21: Breast Mass in a Man
Case 11.22: Gynecomastia
Part III: Special Issues
Chapter 12: Trauma, Burns, and Sepsis
Key Thoughts
Case 12.1: Primary and Secondary Assessment of Injuries
◆ How should the evaluation proceed?
Table 12-1: Priorities in Trauma Evaluation
Table 12-2: Glasgow Coma Scale
Case 12.2: Initial Airway Management
◆ How is the initial airway evaluation performed?
◆ What are other indications for intubation?
Case 12.3: Initial Pulmonary Management
◆ What is the next step?
Figure 12-1: Simple pneumothorax.
◆ What is the next step?
◆ What management is appropriate for a patient with a chest tube?
Figure 12-2: Treatment of a pneumothorax involves insertion of a chest tube. The tube isconnected to an underwater seal drainage system to allow fl uid and air to escape from thepleural space but not enter the space; thus, the lung remains expanded. A: Location for insertionof chest tube. B: Insertion of hemostat into pleural space. C: Palpation of pleural space to becertain no vital structures are adherent and likely to be injured. D: Insertion of the chest tube.
◆ How does the proposed management change in the following situations?
Case Variation 12.3.1. Further examination indicates a laceration on the chestwall that penetrates through to the lung and “sucks” air as it moves in andout during respiration.
Case Variation 12.3.2. After insertion of the chest tube and repeating theCXR, the lung does not fully infl ate.
Case Variation 12.3.3. After insertion of a chest tube, a large amount of aircontinues to leak into the chest tube over the next 6 hours, and the lungremains only partially infl ated.
Case Variation 12.3.4. A very small pneumothorax is apparent on CXR. Yourresident asks you if simple observation and no insertion of a chest tube will beeffective.
Case 12.4: Initial Management of Pneumothorax in a Patient with Hypotension
Case 12.5: Initial Management of Hypotension and Neck Vein Distention with Normal Breath Sounds
Case 12.6: Initial Management of Hypotension with Normal Breath Sounds and No Neck Vein Distention
◆ What are the appropriate steps in the initial resuscitation?
◆ How is the amount of blood loss estimated based on the patient’s initialpresentation?
Table 12-3: Classifi cation of Estimated Fluid and Blood Shock in Adults:Requirements Based on Initial Presentation*
◆ How is the adequacy of resuscitation estimated?
◆ What additional management is necessary?
◆ Is it necessary to have a central venous catheter or pulmonary arterycatheter to manage this patient properly?
DeepTh oughts
Case Variation 12.6.1. Signifi cant hypotension continues despiteresuscitation, no thoracic injury, and no obvious major long bone or softtissue injuries.
Case Variation 12.6.2. Signifi cant hypotension continues despiteresuscitation, no thoracic injury, and no obvious major long bone or softtissue injuries but in the presence of a closed head injury.
◆ Is the closed head injury a likely cause of the hypotension in addition to apossible abdominal or pelvic injury?
Case Variation 12.6.3. Suppose the patient is a pregnant woman in her thirdtrimester.
◆ What hemodynamic effects of pregnancy might be importantconsiderations?
Case Variation 12.6.4. Suppose you were starting to put in the urinarycatheter and you noticed blood at the urethral meatus.
◆ What is the next step?
Case 12.7: Initial Cervical Spine Management
Case Variation 12.7.1. The patient is awake and alert.
Figure 12-6: A: On lateral radiography, the seven cervical vertebrae plus the top of the bodyof T1 should be visible. B: Injuries are suspected if a bony structure is fractured or crushed.Other indications of injury include misalignment of the vertebrae, fl uid in the prevertebralspace, “step-offs” from one vertebra to another, fracture of the odontoid, and misalignmentof the facet joints. C: Number 1 shows the proper alignment of C1 and C2, number 2 showsnormal disk space and vertebral alignment, number 3 shows normal vertebral body structureand forces in a shearing fracture, and number 4 shows normal canal for spinal cord.
Figure 12-7: To safely intubate a trauma patient, an assistant must maintain stability andin-line traction to prevent injury to the potentially unstable cervical spine.
Case Variation 12.7.2. The patient is comatose.
Case Variation 12.7.3. The patient has loss of neurologic function belowthe neck.
Case Variation 12.7.4. The patient has priapism.
Case 12.8: Initial Assessment of Thoracic Injury
◆ Is any immediate action necessary?
◆ What management is appropriate in the following situations?
Case Variation 12.8.1. Immediately, 1,700 mL of blood is evacuated.
Case Variation 12.8.2. The initial volume output from the chest tube is1,000 mL, but the patient continues to have blood loss from the chest tube.
Case Variation 12.8.3. The patient initially presents with hypotension with aBP of 80/50 mm Hg.
Case Variation 12.8.4. The injury is immediately inferior to the clavicle.
Case Variation 12.8.5. The injury is below the nipple on the left side(Fig. 12-10).
Figure 12-8: Chest radiograph demonstrating a right hemothorax (arrow ) with multiple ribfractures.
Figure 12-9: Penetrating injuries immediately below the clavicle can injure many vascularstructures.
Case 12.9: Management of an Indistinct or Widened Mediastinum
Case 12.10: Initial Abdominal Assessment Based on Mechanism of Injury
Case 12.11: Initial Assessment of Abdominal Injury
Case 12.12: Management of Abdominal Injuries Visible on CT Scan
Case 12.13: Management of Operative Findings with Abdominal Trauma
Case 12.14: Initial Neurologic Injury Assessment and Management
Case 12.15: Other Neurologic Problems
Case 12.16: Management of Continuing Hemorrhage
Case 12.17: Management of Postoperative Problems in Trauma Patients
Case 12.18: Traumatic Arteriovenous Fistula
Case 12.19: Management of Continuing Pulmonary Problems
◆ What is the correct interpretation and management of the following situations?
Case Variation 12.19.1. Severe rib pain
Case Variation 12.19.2. Pulse oximetry of 90% and a respiratory rate of28 breaths per minute
◆ What is the diagnosis and management?
Figure 12-25: A fl ail chest causes a mobile segment of chest wall that moves paradoxicallywith respiration. A: Anterior view. B: Posterior view. C: Lateral view.
Case Variation 12.19.3. Chest injury requiring a chest tube
Case 12.20: Management of Respiratory Distress
◆ How should the following conditions be interpreted and managed?
Case Variation 12.20.1. P CO 2 of 55 mm Hg
Case Variation 12.20.2. P CO 2 of 25 mm Hg
Case Variation 12.20.3. You increase her F IO 2 to 60%, which fails to increasethe patient’s oxygenation above 56 mm Hg.
Case Variation 12.20.4. You increase her F IO 2 to 80%, which still does notimprove oxygenation.
◆ She is now on PEEP. How would you manage the following situations?
Case Variation 12.20.5. When you add 10 cm H 2 O PEEP, it results in a declinein BP from 120/80 mm Hg to 90/60 mm Hg.
Case Variation 12.20.6. When you add 10 cm H 2 O PEEP, it results in a declinein the patient’s urine output, which remains at 10 mL/hr.
◆ What intervention is appropriate?
Case 12.21: Stab Wound to the Neck
Case 12.22: Other Injuries to the Neck
Case 12.23: Burn
Case 12.24: Total Parenteral Nutrition
Chapter 13: Congenital Anomalies
Key Thoughts
Case 13.1: Acute Respiratory Distress
Case 13.2: Respiratory Distress with Oral Intake
Case 13.3: Bilious Emesis
Case 13.4: Imperforate Anus
Case 13.5: Vomiting in a 2-Week-Old
Case 13.6: Abdominal Wall Defects
Case 13.7: Abdominal Pain in a 1-Year-Old
Index

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NMS

National Medical Series For Independent Study

Case Bruce E. Jarrell Eric D. Strauch

00

Second Edition

+ Cll nicaJ cases for Independent study and USM LE Step 2 preparation

+ Complied by experts In surgical education and experienced contributing authors

+ Question and answer coverage helps guide re