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A patient with a clear clinical picture of sciatic dislocation of the right hip was admitted to the emergency room. After local anesthesia in combination with subcutaneous injection of 2 ml of 1% morphine solution, without making an X-ray of the damaged area, the dislocation was corrected according to Kocher. After that, he immobilized the right lower extremity with the help of a posterior plaster cast, fixing the hip, knee and ankle joints. The victim was hospitalized. Are the doctor’s actions correct?
The doctor’s actions are wrong. In all cases of traumatic dislocation, in order to exclude concomitant fractures, it is necessary to make X-ray images of the damaged area before the dislocation is reduced. In addition, after the dislocation has been reduced, control X-rays should be taken to objectively confirm the dislocation has been reduced.
A patient was admitted to the hospital with a refined diagnosis: a closed screw-shaped fracture of both bones of the left leg in the middle third. What type of treatment is more rational to use?
In such cases, it is better to inject 20-25 ml of a 2% solution of novocaine into the fracture site immediately after the patient is admitted and perform skeletal traction. The fact is that a plaster cast for screw-shaped fractures of the lower leg does not prevent secondary displacement of bone fragments.
Patient M., 50 years old, slipped, fell on the steps of the porch, hit his right hip. Complains of hip pain. Can’t get up. The right lower limb is 5 cm shorter than the left one, the foot is rotated outward. The pulse on the right dorsal artery of the foot is satisfactory filling. The thigh is increased in volume, deformed, its palpation is painful in the middle third. False mobility is also determined here. What is your clinical diagnosis? What should be the actions of an ambulance doctor?
A patient has a clinical picture of a closed fracture of the diaphysis of the right femur with displacement of fragments along the length.
In order to relieve pain and prevent shock, the victim should be injected subcutaneously 1-2 ml of 1% morphine solution, 2 ml of 20% camphor solution. The limb must be splinted with a Dieterichs splint or Kramer splints. When the thigh is splinted, immobilization of all three large joints is necessary: the hip, knee and ankle. When splinting with Kramer tires, you need to tie two of them together to make one length from the armpit to the heel. Then the prepared tires are applied in this way: a long one along the outer surface, and a short one along the inner surface of the leg. Tires are tightly bandaged to the victim’s leg over clothing.
A patient on a stretcher must be taken to a hospital.
A 14-year-old boy, playing volleyball, fell on his outstretched left arm. Pain in the left clavicle is troubling. The position of the victim is forced: the body is tilted towards the injury, the healthy hand supports the forearm of the injured arm bent at the elbow and presses it to the body. The pulse on the left radial artery was satisfactory filling, the sensitivity of the fingers was preserved. There is moderate, swelling and tenderness on palpation in the region of the left clavicle. Active and passive movements in the left shoulder joint are severely limited due to pain. What is your diagnosis? What is the first aid that should be given to the patient? What additional examinations is necessary for the victim and what is the further treatment tactics?
Based on clinical data, the boy has a closed traumatic fracture of the left clavicle. In order to provide first aid, it is necessary to inject an anesthetic and fix the left hand so that the shoulder joint, and therefore the fragments of the clavicle, become motionless. This can be achieved by applying immobilizing bandages (Dezo, Velpo, etc.) or by hanging your hand on a scarf.
To clarify the diagnosis, be sure to take an X-ray of the clavicle.
For clavicle fractures without displacement or with a slight displacement, you can limit yourself to the imposition of an eight-band dressing or Delbe’s rings for two to three weeks.
A 67-year-old man came to the emergency room of the hospital with complaints about pain in both temporomandibular joints, which appeared during yawning. On examination, the patient’s mouth is open, the teeth touch only in areas of painters, chin protrudes forward, cheeks are flattened, chewing muscles are tense. What is your diagnosis? What kind of help and how should the patient be provided?
The patient has a clinical picture of bilateral dislocation of the lower jaw. The dislocation must be corrected. To do this, a 1% solution of novocaine must be injected into the area of the temporomandibular joints.
It is preferable to sit the patient in a dental chair, fix his head on the headrest. Having wrapped the thumbs in a towel, the doctor presses them on the chewing surface of the molars, covering the lower jaw with the rest of the fingers from below, and thus shifts the lower jaw down and forward, and then, with a backward and upward movement, directs the articular heads into the fossa, while feeling a characteristic click. After the dislocation is reduced, it is recommended to restrict the movement of the jaw with a sling-like bandage for 1.5-2 weeks.
A patient who was bitten by a stray dog 3 hours ago was delivered to the surgical office of the district polyclinic. Examination of the right leg revealed six bitten-lacerated wounds filled with blood clots, with slight swelling and soreness around. How much help should be provided to the patient?
Bite wounds are not sutured. It is necessary to toilet the wounds, treat the skin around them with an iodine-containing antiseptic and apply an aseptic bandage. In addition, the patient should be vaccinated against rabies (rabies) and tetanus.
On the 4th day after appendectomy, on the 4th day after appendectomy, against the background of complete subsidence, twitching pains in the area of the postoperative wound reappeared, the temperature increased, and leukocytosis was noted. What should you think about? What are the tactics for further treatment?
In the patient, suppuration of the postoperative wound should be assumed. In the presence of local hyperemia of the edges, swelling, edema, infiltration or softening, it is necessary to probe the wound between the seams with a grooved or bulbous probe. When pus develops, the stitches must be removed immediately, the edges of the wound are divorced. After that, a thorough toilet of the wound and its drainage with turundas with hypertonic sodium chloride solution or with ointments on a water-soluble basis (“Levomekol”, “Levosin”, “Reparef-1”, dioxidine, etc.) are performed.
You have been asked to provide first aid to a young man who fell off a motorcycle half an hour ago. On the outer surface of the right leg there is a large bruised and lacerated wound contaminated with sand and dry grass. Do you have a car first aid kit? How much assistance will you provide to the victim?
After applying pain relievers, foreign bodies visible to the eye are carefully removed from the wound. The skin around the wound must be treated with a 3% alcohol solution of iodine and a sterile bandage (spiral with a bend of the bandage) applied to the lower leg. After that, it is necessary to organize the delivery of the victim to a medical institution, where it is possible to provide qualified assistance.
Do not rinse or wipe the wound with water before applying the dressing.
A victim was delivered to the emergency room with a 2.5×0.4 cm cut wound in the upper third of the right forearm, which was inflicted by an unknown person 2 hours ago with a penknife. How much surgical care should be provided to the patient?
The victim has a fresh cut wound with smooth and necrosis-free edges, which makes it possible to count on primary healing. In order to prevent secondary infection, the skin around the wound should be treated with an antiseptic solution, the wound should be washed with an antiseptic solution, the bleeding vessels should be ligated and primary sutures should be applied.
Do not forget about emergency specific prophylaxis of tetanus!
A victim with a lacerated wound of the left thigh was admitted to the surgical department. 12 hours have passed since the injury. There is a slight swelling of tissues in the area of the wound, the edges of the latter are uneven, bluish. What treatment tactics will you choose?
In this case, even in the absence of signs of infection, it is not worth relying on wound healing by primary intention without surgical treatment.
In the operating room, the wound should be widely dissected so that all its parts can be seen in depth, necrotic and non-viable tissues can be excised and primary sutures applied. Between the sutures, the wound must be drained with rubber strips.
Tetanus prophylaxis is mandatory.
A victim was delivered to the trauma center with a slanting infected cut wound on the palmar surface of the right hand. There are no active flexion movements in the interphalangeal joints of the II-V fingers. What anatomical structures are damaged? What is your treatment strategy?
The victim has an infected cut wound of the right hand with the intersection of the tendons of the superficial and deep flexors of the II-V fingers.
It is necessary to treat the skin around the wound with an iodine-containing antiseptic, to finally stop bleeding, rinse the wound with antiseptic solutions and apply sutures.
It is not recommended to put a primary suture on tendons, including nerves. The latter can only be brought closer together.
A victim came to the emergency room with a blind stab and cut wound in his left shoulder. He was wounded 4 days ago. In the area of the wound, swelling, soreness are determined. A scanty purulent discharge is discharged from the wound. The emergency room surgeon performed a thorough toilet, tamped her tightly with a tampon moistened with a hypertonic sodium chloride solution, and applied a bandage. The patient underwent emergency specific prophylaxis of tetanus. What mistake was made by the surgeon?
The mistake is that the wound was tightly (!) Tamponed, which undoubtedly prevents the outflow of the wound contents.
The victim was delivered to the trauma center with extensive scalp wound to the scalp. The injury occurred 1.5-2h ago. Vaccinated against tetanus. How much qualified assistance should be provided to a patient?
First of all, it is necessary to cut the hair widely around the wound. The wound must be thoroughly cleaned of contamination, rinsed abundantly with antiseptics, the subcutaneous fatty tissue must be completely removed from the scalped skin flap, and its crushed, cyanotic and blood-imbibed edges must be excised. Further, in a checkerboard pattern, perforated holes are applied on the scalped flap. The latter is laid on the wound and fixed with separate sutures to its edges.
A victim was taken to the local hospital, who had cut off the second and third fingers of his right hand with a circular saw the day before. The severed fingers were saved and brought with us. What will you do?
The stumps of the fingers must be treated with antiseptics, apply a pressure bandage. The patient needs to be injected with anesthetic, vaccinated against tetanus and arrange for his delivery to the microsurgical department along with the amputated fingers wrapped in sterile material and placed in a plastic bag. In case of long-term transportation, the amputated fingers should be pre-cleaned of dirt, rinsed abundantly with antiseptics, wrapped in sterile material and put in a cellophane bag. The latter must be placed in a second bag, pre-filled with pieces of ice.
A boy was taken to the local hospital, who was bitten by a snake half an hour ago. The child complains of pain in the right foot, is lethargic, drowsy. On the back of the foot, there are two punctate wounds with hemorrhage around and pronounced edema. Your actions?
The victim above the bite site must immediately apply a tourniquet in order to create venous stasis (clamping of the arteries is unacceptable!). 10 ml of polyvalent antitoxic anti-snake serum are injected intramuscularly into the bite site and in the interscapular region. The poison from the wounds can be sucked off with a blood-sucking jar or, in extreme cases, with the mouth, and sometimes even the site of the bite is excised. Rest should be created for the affected limb for 3-4 days. It is advisable to perform a circular novocaine blockade of the bite site with a 0.5% solution of novocaine with 0.1-0.2 ml of a 0.1% solution of adrenaline, and also intravenously inject 5 ml of a 10% solution of calcium chloride.
In addition, symptomatic agents are prescribed: hydrocortisone, pain relievers, analeptics, antibiotics.
A boy was brought to the clinic from school with complaints of a wound in the neck. According to the victim, he fell on the tip of a chemical pencil. On the right, at the front edge of the middle third of the sternocleidomastoid muscle, there is a punctate wound and swelling around. A foreign body measuring 0.2×0.5 cm is subcutaneously determined near the wound. You are a surgeon. What help should be given to a child?
Wounds contaminated with an “ink” pencil heal extremely slowly. Therefore, it is necessary to immediately excise the site of injury with the removal of the pencil tip and apply provisional stitches to the wound.
A victim with flame burns was taken to the hospital. Both upper limbs are hyperemic, covered with bubbles with amber fluid. The front surface of the body has a “marbled appearance”, the wound surface is painless. On the right thigh over its entire surface (circularly), charring of the epidermis is noted, thrombosed veins are visible. How would you formulate a diagnosis? Having determined the degree and area of the lesion, how do you write down the burn formula?
The diagnosis must be formulated as follows: burn disease, period of shock; thermal burns by flame of the upper extremities of the I-II stage, the front over
Burn formula: S = I-II-IIIA-ШB-IV
You are a doctor at a factory first-aid post and you turned out to be an unwitting witness to an accident: a worker, through negligence, spilled concentrated sulfuric acid on his hand. What kind of assistance will you provide to the victim?
Rinsing the victim’s hand with running water should be started immediately. After that, you should apply a bandage with a solution of soda and send the victim to the hospital.
A victim in a state of burn shock was delivered to the intensive care and resuscitation ward. The affected area is 50% of the body surface. The patient’s body weight is 80 kg. You are a ward doctor. What volumes of colloidal and crystalloid solutions for intravenous infusion anti-shock therapy will you prescribe to the patient on the first day? How fast will you inject solutions?
On the first day of anti-shock therapy, the victim must be poured 4 liters of colloidal and the same amount of crystalloid solutions. The calculation is made separately for colloidal and crystalloid solutions according to the formula: 1 ml of solution x body weight (in kg) x% burn.
In the first 6 hours, 50% of the daily dose (4 liters) is injected and the rest of the amount (4 liters) in the remaining time.
You are an ambulance doctor, arrived on call to a 5-year-old child who overturned a pot of boiling water about 0.5 hours ago. The child is pale, screams, he has chills, acrocyanosis, there was a single vomiting. The anterior surface of the trunk and upper limbs are hyperemic with scraps of exfoliated epidermis. In some areas, the wound surface is whitish. What is your diagnosis? What will be your actions?
The child has a burn disease, a period of burn shock.
It is necessary to introduce painkillers, give a warm drink, apply aseptic dressings moistened with a solution of novocaine on burn wounds, and deliver the patient to the surgical department of a regional hospital or to a specialized burn department. If possible, infusion therapy should be started in the ambulance.
A patient came to the polyclinic with complaints of a long-term non-healing wound on the back of the foot. When interviewed, it was found that two months ago he knocked over a frying pan with boiling fat on his leg. He was treated with folk remedies. Visually, on the back of the right foot, a granulating wound with remnants of a dense necrotic scab of black color and moderate purulent discharge is determined. What is the degree of the burn? What is your treatment strategy?
The victim has a deep burn of the right foot. He is shown excision of the remains of a necrotic scab (mechanical necrectomy) and autodermoplasty. Therefore, in the clinic, a bandage with an antiseptic solution should be applied to the foot and the patient should be sent to a surgical hospital.
A 20-year-old man was delivered to the trauma center by ambulance. According to the victim, while working, he came under the influence of an electric current with a voltage of 380V (took hold of the wire with his hands). Lost consciousness. Charred skin is detected on the palmar surfaces of the hands. The general condition of the applicant is satisfactory. What are the possible consequences of the trauma suffered? Your actions?
The victim has a risk of cardiac arrest due to deep necrosis of the muscles of the upper limbs. Therefore, in the trauma center, aseptic bandages should be applied to the hands and the patient must be admitted to the hospital for examination and dynamic observation. The examination plan should include electrocardiography.
An ambulance car delivered a victim from the scene of the accident to the trauma center with a diagnosis of I-II degree electric burn of the face and hands. When collecting the anamnesis, it was found that during the repair of the electrical appliance, an electric arc outbreak occurred, as a result of which the patient received burns of the indicated parts of the body. The face is moderately edematous, against the background of its hyperemia, a smoky epidermis is determined in patches. Eyes watery, photophobia is noted. The brushes are hyperemic, with many small blisters. What is the mistake of an ambulance doctor? What is your diagnosis? Which specialist will you contact for advice?
The ambulance doctor misdiagnosed.
This is not an electric burn, but a thermal burn from an electric arc flash. Correctly the diagnosis should be formulated as follows: thermal burns of the I-II degree of the face and hands by an electric arc flash; electrophthalmia. The victim needs the advice of an ophthalmologist.
The woman was boiling her laundry. I added washing powder and bleach to the water. When removing the container from the stove, the victim, through negligence, knocked it over on herself, and received burns. The anterior surface of the trunk, forearm and hand are hyperemic, the wound surface is whitish with poor pain sensitivity. Having determined the degree and area of the burn, how would you formulate a diagnosis? What first aid do you provide?
The diagnosis is formulated as follows: burn disease, shock; thermal burns of the front surface of the body, forearms and hands.
Burn formula: o -.
1 II ™ – 111 / Y
A victim with burns must be given painkillers, aseptic dressings with a solution of novocaine, and transportation to the hospital.
The victim was taken to the admission department of the hospital from the scene of the fire. Consciousness is darkened. The face and hands are smoked, the nose and lips are burnt. Breathing is shallow, there is occasional coughing, expectoration of sputum mixed with burning. What is your diagnosis and action?
The patient has thermal burns of the face and hands, inhalation trauma (burns of the respiratory tract and toxic smoke inhalation).
After taking material for a general analysis of blood and urine, performing an ECG, X-ray examination of the lungs and examination by a therapist, according to emergency indications, the patient should be hospitalized in the intensive care unit.
A 3-year-old child with thermal burns on the back of the torso and buttocks was delivered to the hospital emergency room by an ambulance. According to the mother, the child sat down in a pot of boiling water that was on the floor. The child’s condition is serious. In the accompanying sheet, the doctor of the ambulance brigade noted that the burn surface was treated with Oxycyclosol aerosol and covered with an aseptic bandage. What is the mistake of an ambulance doctor and what should have been done when providing first aid?
It is impossible to treat the burned surface with “Oxycyclosol”, as this aggravates the pain and aggravates the victim’s condition.
When providing first aid, the child had to cool the wound, inject painkillers, apply an aseptic dressing with a solution of novocaine, which the ambulance doctor did not do.
You are an emergency doctor. We arrived on call. An unconscious man is lying on the street. Air temperature -20 C, wind. When examining the patient, there is a sharp pallor of the skin of the hands, the capillary pulse is not detected, the fingers are covered with a crust of ice. What is your diagnosis and action?
The victim has general hypothermia, severe cold injury to the hands, pre-reactive period. It is necessary to put heat-insulating bandages on the hands and deliver the patient to the hospital.
A victim was admitted to the surgical department with complaints of lack of sensitivity in the toes, their swelling. When collecting anamnesis, it was found that public transport had been waiting for a long time in the cold the day before. I chilled myself and my toes froze. At home I warmed my feet in a hot bath, but sensitivity did not recover. The feet are edematous, there is cyanosis of the fingers, lack of sensitivity in them, the capillary test is negative. What is your diagnosis and treatment?
In the victim, frostbite of III-IV degree of the toes can be predicted. He urgently needs to apply heat-insulating bandages to his feet and begin to carry out complex treatment, including intra-arterial infusions of vasodilators, anticoagulants, antiplatelet agents, rheological drugs, thrombolytic therapy to restore blood circulation in the affected segments.
A victim with frostbite of both feet in the late reactive period was delivered from the district hospital to the clinic. The patient’s condition is grave. Both feet are edematous, there is a sharp cyanosis of the skin on them with a gray tint, sensitivity is completely absent. Blisters with purulent content along the lines of demarcation. The skin on the legs is hyperemic. Body temperature -38C. What is your diagnosis, additional examinations and treatment tactics?
The patient has frostbite of the feet of the IV degree, wet gangrene, phenomena of ascending inflammation and severe intoxication. Generalization of the infection is possible.
It is necessary to check the blood for sterility, to inoculate the pus from the blisters on the microflora and its sensitivity to antibiotics.
The patient is prescribed infusion detoxification therapy, complex antibacterial treatment. In addition, necrectomy should be performed on the feet.
On the fifth day after the injury, a patient with frostbites of the feet of III-IV degrees began to complain of weakness, fever up to 39 C, cough, shortness of breath. Both feet are edematous, the skin of the legs is hyperemic. What complications could the patient develop? What additional examinations will you conduct to clarify the diagnosis? What is your treatment strategy?
In the reactive period of cold injury, the patient may develop pneumonia or sepsis.
To clarify the diagnosis, it is necessary to conduct an X-ray examination of the lungs and a blood test from a vein for sterility.
In addition, necrectomy on the feet should be performed and detoxification and antibacterial therapy should be continued.
You arrived at the scene on call. According to those present, a few minutes ago the victim was exposed to an electric current. Lost consciousness. Convulsions have occurred. Work friends turned off the switch. The patient lies on the floor. There is no breathing, the pulse is not palpable, the skin is cyanotic, the pupils are wide, and they do not react to light. What about the victim? Your actions?
The victim suffered cardiac arrest and respiratory arrest after a severe electrical injury. It is urgent to start artificial ventilation of the lungs and closed heart massage to remove the patient from the state of clinical death.
A patient was admitted to the surgical department, who two days ago received an electric burn of the right hand of the IV degree. The hand, forearm and shoulder are sharply edematous, woody density. Sensitivity in the fingers of the hand is weakened. What kind of emergency surgery should you perform?
In this situation, the patient should immediately perform decompressive fasciotomy on the shoulder and forearm with longitudinal stripe incisions to prevent secondary myonecrosis.
ACUTE PURULENT SURGICAL INFECTION
A young man with a boil on his upper lip came to the clinic for an appointment with the surgeon. The body temperature is 39 C. The swelling of the upper lip and eyelids is expressed. What should the surgeon do with the patient? What treatment should be done?
With the localization of the boil on the face above the corners of the mouth, it is possible to develop progressive thrombophlebitis of the facial veins, which, through the veins of the corners of the eyes, can pass into the system of the ophthalmic vein and then into the cavernous sinus of the skull. Purulent thrombosis of the cavernous sinus is almost always accompanied by purulent basal meningitis and optochiasmatic arachnoiditis – the most severe and usually fatal complications. Therefore, the patient must be hospitalized. Bed rest is prescribed, intensive antibiotic therapy is carried out, anticoagulants, antistaphylococcal gamma globulin, plasma are shown. The skin in the boil area must be cleaned with 70% ethyl or 2% salicylic alcohol. You can apply a bandage with an antibiotic ointment.
A 50-year-old woman with interscapular carbuncle was admitted to the surgical department two days after the onset of the disease. Blood test: leukocytes-11.5×10 / l, stab-b / ESR-17 mm / h, sugar 4.6 mmol / l. Despite the ongoing conservative treatment (antibiotics, sulfonamides, vitamins, antistaphylaccoccal gamma globulin, local trypsin, UHF), the inflammatory-necrotic process continues to progress, and general intoxication has increased. What should be the further tactics of treating the patient?
The lack of effect of conservative treatment, the progression of the local inflammatory necrotic process, the increase in intoxication are indications for surgical treatment.
The carbuncle is dissected with a cruciform or H-shaped incision with excision of all purulent-necrotic tissues. The resulting cavity is washed with a 3% solution of hydrogen peroxide, a solution of furacilin and drained with a turunda moistened with a hypertonic solution of sodium chloride or an ointment on a water-soluble basis.
For cosmetic reasons, significant skin defects after granulation wound should be closed with a free Thirsch or dermatomal skin graft.
A patient came to see the surgeon complaining of pain in the right axillary region, aggravated by movement in the right shoulder joint. The third day is ill. Examination in the axillary region revealed 3 dense limited infiltrates with a diameter of 0.8 to 1.2 cm, slightly protruding above the skin, with slight hyperemia of the latter above them. What happened to the patient? What should be the treatment tactics?
The patient has right-sided axillary hydradenitis without signs of abscess formation.
Treatment should begin with a toilet of the skin in this area: cut or shave off the hair, wipe the skin with alcohol, treat with iodonate. Then a dry or synthomycin emulsion dressing is applied. It is best to apply a spike-shaped bandage to the armpit and shoulder girdle so that the bandage fits snugly to the skin and does not sag. A short novocaine blockade with antibiotics and UHF therapy give a good effect in the initial stages of the disease.
With abscess formation of hydradenitis, the abscesses are opened with cuts over the inflammatory foci longitudinally to the axis of the limb.
Patient K., 26 years old, complains of pain in the right hand for 4 days. Pain first appeared at the site of calluses on the palmar surface at the bases of I and III fingers. Subsequently, edema and swelling of the rear of the hand began to rapidly increase. The II and III fingers are bent at the interphalangeal joints, unbent and divorced at the metacarpophalangeal joints, the hand looks like a “rake”. What is your diagnosis and treatment tactics for this patient?
A patient has phlegmon of the second interdigital space of the right hand. He needs surgical treatment in combination with hand immobilization. After treatment under local or general anesthesia, the abscess must be opened in the zone of maximum pain along the palmar surface with a longitudinal incision in the interdigital space without or with a counterperture on the back of the hand. A thorough toilet and wound drainage are performed. An aseptic bandage is applied. The brush should be immobilized with a dorsal plaster cast.
A patient was admitted to the emergency room of the hospital with complaints of pain in the left buttock and chills. Body temperature 38.9C. The patient considers himself 2 weeks, when due to high blood pressure an ambulance paramedic in the left buttock was injected with a solution of magnosulfate. When viewed in the upper-outer quadrant of the left buttock, skin hyperemia, swelling are determined, a softening area is noted in the center of a dense, painful and filtrate. Blood analysis; leukocytes-12.2×10 / l, shelly-7 /, segmented-74 /, ESR-26 mm / h.What should be assumed in the patient? How can you be sure of the correct diagnosis? What should be the treatment tactics.
The patient should assume the presence of a post-injection abscess of the left buttock. To confirm the diagnosis at the site of softening, a diagnostic puncture with a thick needle should be performed.
When pus is obtained (bacterial sowing!), Incision is made through the needle, a finger is used to revise the abscess cavity in order to destroy possible partitions in it. After evacuation of pus and thorough washing of the purulent cavity with antiseptics (solutions of hydrogen peroxide, furacilin, chlorhexidine, etc.), the abscess cavity must be drained with a swab moistened with a hypertonic solution, an adhesive bandage should be applied and antibiotics should be prescribed.
An elderly man three days ago was re-operated for postoperative peritonitis (failure of the sutures of the small-intestinal anastomosis). The patient complains of pain in the wound, dry mouth, thirst. Body temperature 37.6-38.5 C. Tongue dry, overlaid with a dirty gray bloom. Hyposalivation is expressed. There is a slight pain in the area of the right-handed gland. What kind of complication is possible? What preventive measures should be taken?
The patient may develop postoperative mumps.
To prevent this complication, it is necessary: 1) to sanitize the oral cavity before surgery (treatment of periodontal disease, caries, chronic tonsillitis, etc.);
2) to treat the oral cavity with antiseptic solutions in the next hours of the postoperative period, and subsequently brushing the teeth is required; 3) recommend sucking slices of lemon, orange, apple, drinking sour fruit drink in order to stimulate salivation.
A 70-year-old man on the 3rd day after surgery began to complain of pain in the parotid gland, difficulty and soreness when opening his mouth. Body temperature 38-39C. In the parotid region, a dense painful infiltrate is determined. Shifted leukocytosis in the blood formulas to the left, increased ESR. What complication should the patient be thinking? What is your treatment strategy?
The patient has developed postoperative parotitis. Treatment should include:
- 1) broad-spectrum antibiotics;
- 2) frequent rinsing of the mouth with a furacilin solution;
- 3) careful washing of the excretory duct of the parotid salivary gland (this procedure should be performed by the dentist);
- 4) ionogalvanization of antibiotics and proteolytic enzymes to the infiltration area;
- 5) semi-alcoholic or with 10-20% Dimexin solution compresses on the infiltrate area;
- 6) intravenous administration of kontrikal (tsalol, gordox).
If, within 3-4 days, conservative treatment does not give an effect, then you should resort to surgery until fluctuation appears. Most often, the incision is made around the corner of the lower jaw 1 cm below the base of the earlobe, parallel to the edge of the masseter muscle, so as not to damage the branches of the facial nerve. A second typical incision is made transversely, 2 cm forward from the base of the earlobe towards the wing of the nose.
In the evening, a young woman was hospitalized in a surgical hospital 16 days after childbirth with complaints of pain in the right mammary gland, chills. Has been ill for more than a week. I was self-medicating, but it had no effect. body temperature 39.9 C. The right mammary gland is enlarged. In its lower quadrants, an extensive, dense, painful infiltrate with a softening in the center is deeply palpated. Axillary lymph nodes on the right are enlarged and painful. What is your diagnosis? What should the surgeon on duty do? What about feeding a baby?
The patient has postpartum intramammary purulent mastitis, complicated by lymphadenitis. To verify the diagnosis, puncture of the abscess with a thick (!) Needle should be performed. The resulting pus is examined for microflora and antibiotic sensitivity.
The abscess must be opened immediately under intravenous anesthesia. In this case, the most suitable is the Bardenheier approach, the essence of which is to perform an arcuate incision parallel to the transitional fold of the mammary gland, departing from it about 1 cm.The gland is exfoliated and displaced upward, then an incision is made along the posterior surface of the gland tissue itself. The pus is evacuated, the wound is washed and drained.
Milk must be expressed (or better sucked off) from both mammary glands. It should be given to the child after preliminary pasteurization or boiling. The postoperative period proceeds under the guise of antibiotics.
A patient was admitted to the surgical department with complaints of pain in the left mammary gland for 6 days. Breastfeed. The child is 12 days old. The skin is pale. In the upper outer quadrant of the left breast, a painful compaction with a diameter of up to 6-7 cm is determined. with indistinctly differentiated softening in the center. What diagnosis will you make. What is your treatment and diagnostic tactics?
A patient has acute postpartum purulent mastitis. To verify the diagnosis, it is necessary to puncture the alleged abscess.
Upon receipt of pus (bacterial culture!), The abscess of the mammary gland under intravenous anesthesia should be opened. In this case, Angerer’s access is the most rational: a radial incision is made, departing from the areola 2-3 cm. It is obligatory to revise the abscess cavity with a finger. After emptying the abscess, the cavity of the latter is washed with an antiseptic and drained with a tampon moistened with a hypertonic sodium chloride solution. The woman is advised to express milk or, best of all, use a breast pump for this.
If it is necessary to suppress lactation, injections of camphor are prescribed, a combination of female and male sex hormones: 1 ml of a 0.1% solution of sinestrol in combination with 1 ml of a 1% solution of testosterone, 2.5 mg of parlodel (ergobromryptin) 2 times a day for 3-7 days.
A woman came to the surgeon’s appointment with complaints of pain in the nipple of the left breast 2 months after giving birth. Areola is edematous. There is swelling, infiltration into its low semicircles with clear fluctuations in the center. What is your diagnosis and treatment tactics?
A patient has acute postpartum subareolar purulent mastitis. Surgical treatment is indicated. For cosmetic reasons, in this case, it is preferable to perform an arcuate incision at the border of the areola. The milk ducts here are usually small and located deep under the abscess, which reduces the risk of damage.
A nursing mother, within 2 months after the opening of purulent mastitis in the upper outer quadrant of the right breast, has a punctate fistula with constant release of drops from it in the form of milk. Conservative measures aimed at closing the fistula did not give an effect. What will you do?
No active measures are required to close the fistula. The formed milk fistula will heal on its own after the cessation of lactation. Therefore, the patient can be recommended, if necessary, to replace the aseptic dressings with a fistula.
A 15-year-old boy came to the surgeon’s appointment with complaints of pain and hardening in the right breast. He considers himself sick for about 3 weeks. Body temperature is normal. The mammary glands are enlarged, and the right one to a greater extent, They are swollen, dense, painful on palpation. On the pubis, there are signs of male-pattern hair growth. Pathology from the external genital organs is not noted. What about the patient? What are your recommendations?
The patient has pubertal hypertrophy of the mammary glands (mastitis adolescentium). This is a normal physiological response of the body during maturation.
The young man should be advised to engage in physiotherapy exercises, swimming, rubdown with cool water. With a pronounced pain syndrome, cold is applied topically. Surgical treatment is not indicated.
A 46-year-old man came to the clinic surgeon with complaints of an enlargement of the left breast, which he began to notice 1.5 months ago. The body temperature is normal, the left breast gland is increased to 5-6 cm. in diameter, homogeneous dense elastic consistency, painless. Volumetric formations are not defined in it. The nipple is not enlarged. There is no discharge from it. External genital organs were normal. What is your diagnosis and treatment tactics?
The patient has gynecomastia (hypertrophy of the left breast), which is often combined with tumors of the adrenal glands and testicles. If tumors are found, they must be removed. After the operation, as a rule, there is a reverse development of the hypertrophied glands.
In the initial stages of gynecomastia, in the absence of disturbances from other endocrine organs, a two-month course of therapy with methyltestosterone 0.005 g 2 times a day under the tongue is prescribed. If the gland continues to increase or there is a suspicion of cancer, then the removal of the enlarged gland while preserving the nipple and areola is indicated with the obligatory urgent histological examination of the drug.
A 45-year-old woman came to the emergency room of the hospital with complaints of pain in the right leg, headache, weakness, weakness. Has been ill for 2 days. Body temperature in the evenings rises to 39 C. On the antero-outer surface of the lower and middle third of the leg there is an extensive, bright red spot with several small bubbles filled with serous-hemorrhagic exudate. The boundaries of hyperemia are clear, uneven (in the form of a graphic card). At the site of hyperemia, the skin is doughy, sharply painful on palpation. Blood test: leukocytes-15.1×10 / l, stab neutrophils-7 /, ESR-34mm / h. What is your diagnosis? Should the patient be isolated from other patients in the department during hospitalization? What treatment will you prescribe to the patient?
The patient has erysipelas of the right leg, a bullous form. The woman should be admitted to a surgical infection unit, but there is no need to isolate her from other patients.
From therapeutic measures, bed rest, antibiotics (penicillin, ampicillin, oxacillin, methicillin, ampiox), sulfonamides (sulfacil, sulfapyridazine, etazole, etc.) are prescribed. Locally recommended the imposition of a dry aseptic dressing, irradiation with suberythemal doses of ultraviolet rays.
General and local baths, as well as wet dressings for erysipelas, are contraindicated.
A 53-year-old woman came to see a dermatologist with complaints of itching and burning of the skin on the third finger of her left hand. From the anamnesis it became known that 3 days ago the patient was cutting fish at home and pricked her finger with a bone. A day later, there was swelling on the finger, skin redness and pain. When viewed on the dorsal-lateral surface of the finger, a spot of skin hyperemia with a bluish-violet tinge is noted. The edges of the reddening are scalloped. The finger is swollen, movements in the interphalangeal joints are limited, painful. What disease should you think about? What pathology is it necessary to carry out differential diagnostics with? How will you treat the patient? Does she need release from her professional duties?
It should be thought that the patient has erysipeloid of the third finger of the left hand, a skin form.
The disease is caused by the gram-positive bacillus erysipelas (Erysipelothryx rhusiopathiae). Most often, butchers, fishermen, cooks, housewives, veterinarians, hunters, that is, those who are associated with animals, meat, fish products by occupation.
When recognizing erysipeloid, it is necessary to differentiate from cutaneous, subcutaneous and articular panaritium, erysipelas, exudative erythema, trophoneurotic arthritis and rheumatoid infection.
As a therapeutic measure, the patient should be prescribed antibiotics, sulfonamides, ultraviolet irradiation of the finger. It is desirable to immobilize the latter. Topical ointment dressings have no effect.
If the patient’s work is related to the preparation of food, then the patient should be recognized as temporarily disabled and issued a sick leave or recommend to the administration of the enterprise where the woman works to transfer her to another job that excludes contact with food.
Patient K., 26 years old, summoned the local doctor to the house for sore throat, fever, chills. I fell ill a day ago. On examination, the palatine tonsils are significantly enlarged, protrude from the palatine arches, are brightly hyperemic, when pressed on them with a spatula, pus is released. On palpation in both submandibular areas, dense, rounded, mobile, painful formations not adhered to the skin, up to 2-2.5 cm in diameter, are determined. The skin above them is not changed. What happened to the patient? Does he need urgent surgery?
The patient has acute follicular tonsillitis, secondary serous bilateral lymphadenitis. It is desirable to hospitalize him in a therapeutic or ENT department for treatment for the underlying disease. (Secondary lymphadenitis, as a rule, stops on its own as the pathology that caused it is eliminated).
At the time of examination, the patient does not need emergency surgical intervention.
A young man who had been drafted into military service two weeks ago came to see the doctor. Complains of pain in the right foot, which bothers for 3 days. When viewed on the rear of the II-III toes of the right foot, there are abrasions with a purulent bloom. The foot on the dorsum is edematous, and there is also hyperemia in the form of red longitudinal stripes, painful when touched. In the right groin, a moderately painful, densely elastic consistency, the size of a hazelnut knot is palpable. The skin above it is not changed. What is your diagnosis and treatment tactics?
A patient has infected scuffs of II-III toes of the right foot, complicated by serous lymphangitis of the dorsum of the foot and inguinal serous lymphadenitis.
The serviceman should be hospitalized, make a toilet of scuffs, apply bandages with antiseptics. In the early days, bed rest is prescribed with an elevated position of the right lower limb.
From the moment of hospitalization, antibiotics and sulfonamides are prescribed.
Patient N., 36 years old, was admitted to the surgical department for acute pancreatitis. Despite the ongoing treatment, the condition continued to deteriorate. Body temperature is hectic. The phenomenon of peritonitis increased. On urgent grounds, a laparotomy was performed and purulent melting of the pancreas was found. After sanitation of the abdominal cavity, the operation was completed by marsupialization (the edges of the dissected gastro-colonic ligament were sutured to the parietal peritoneum of the anterior abdominal wall). Tampons “cigars” were brought to the affected gland, a drainage tube was placed in the Douglas space. In the postoperative period, the patient’s condition remains extremely difficult. A day after the operation, the tampons were suddenly abundantly saturated with scarlet blood. The pulse increased to 124 beats per minute, blood pressure dropped to 90/60 mm Hg. Art. What is most likely the cause of secondary bleeding in the patient? What is your treatment strategy?
Most likely, the patient, against the background of purulent pancreatitis, developed purulent arteritis, or rather, periarteritis of the vessels supplying the pancreas. As a result of the purulent process, arrosion of the artery wall occurs, rupture of it with subsequent bleeding.
If the bleeding, despite the ongoing conservative measures (cold, vicasol, calcium chloride, epsilon-aminocaproic acid, plasma, blood, etc.), continues, the patient is shown a second emergency operation in order to finally stop the bleeding.