Jeef Surgery notes 1-5

A 60 year old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.
Dx?
Management?

A 60 year old man known to have hemorrhoids complains of anal itching and discomfort, particularly towards the end of the day. He has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile.
Dx?
Management?

A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even “spread her cheeks” to look at the anus for fear of precipitating the pain.
Dx?
Management?
Surgical Tx?

A 28 year old male is brought to the office by his mother. Beginning four months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, but actually the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures all around the anus, with purulent discharge. There are no palpable masses.
Dx?
Diagnostic test?
Top 3 medical Tx?

A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and that he has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between the anus and the ischial tuberosity.
Dx?
Management?

A 62 year old man complains of perianal discomfort, and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. Physical exam shows a perianal opening in the skin, and a cord-liked tract can be palpated going from the opening towards the inside of the anal canal. Brownish purulent discharge can be expressed from the tract.
Dx?
First step?
Tx?

A 55-year old, HIV positive man, has a fungating mass growing out of the anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated and ill.
Dx?
Diagnostic Test?
Eventual Tx?

A 33 year old man vomits a large amount of bright red blood.
Where can the bleeding be from?
Diagnostic test?

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110.
Where is bleeding from?
Management?

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns copious amounts of bright red blood.
Management?

A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns clear, green fluid without blood.
Diagnostic test?

A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood.
Diagnostic test? (2)

A 7 year old boy passes a large bloody bowel movement.
Dx?
Diagnostic test?

A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.
Dx?
Diagnostic test?
How could it have been prevented?
Tx?

A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He lies motionless in the stretcher, is diaphoretic and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.
Dx?
Management?

A 62 year old man with cirrhosis of the liver and ascites, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.
Dx?
Diagnostic test?
Tx?

A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms.
Dx?
Management?

A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization.
Dx?
Diagnostic test?
If Dx is unclear?
Management? (3 together)

A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.
Dx?
Diagnostic test?
Management?

A 52 year old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria.
Dx?
Diagnostic test? (2)

A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.
Dx?
Diagnostic test?
Management?

An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot’s beak.
Dx?
Management?

A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small bowel and distended colon up to the middle of the transverse colon.
Dx?
Tx if mild, moderate or severe?

A 53 year old man with cirrhosis of the liver develops malaise, vague right upper quadrant abdominal discomfort and 20 pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha feto protein is significantly elevated.
Dx?
Diagnostic test?
Tx?

A 53 year old man develops vague right upper quadrant abdominal discomfort and a 20 pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoembryogenic antigen (CEA) had been within normal limits right after his hemicolectomy, is now ten times normal.
Dx?
Diagnostic test?
Tx?

A 24 year old lady develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a hemogoblin of 7. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never misses taking them.
Dx?
Management?
Tx?

A 44 year old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the right upper quadrant. An ultrasound reveals a liver mass.
Dx?
Management?

A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Ultrasound of the right upper abdominal area shows a normal biliary tree, and an abscess in the liver.
Dx?
Management?

A 42 year old lady is jaundiced. She has a total bilirubin of 6 and the laboratory reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is zero. She has no bile in the urine.
Dx?
Management?

A 19 year old college student returns from a trip to Cancun, and two weeks later develops malaise, weakness and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated, while the SGOT and SGPT (transaminases) are very high.
Dx?
Management?