Answers to problems in medicine surgery – Part 5

On this page you will study Answers to problems in medicine surgery (Part 5) from the subject of Medicine, in the proposed topic other questions on Medicine are also sanctified.  If after studying this material you have questions, then you can ask them in the form below, other like-minded people may help you. If you have new questions, ask in the comments or Contact Us on Email (technoashish0@gmail.com)or Whatsapp.

 

Answers to problems in medicine surgery – Part 1

Answers to problems in medicine surgery – Part 2

Answers to problems in medicine surgery – Part 3

Answers to problems in medicine surgery – Part 4

Answers to problems in medicine surgery – Part 5

 

A 51-year-old patient was admitted to the hospital with complaints of shortness of breath due to “valve” closure of the right nasal passage. Periodically notes nosebleeds. On examination, the nasal passage on the right is sharply narrowed due to the rounded shape of the tumor-like formation. On the roentgenogram, pathology from the nasal bones is not noted. What is your diagnosis and treatment tactics?

The patient most likely has a papilloma of the right nasal passage. Because the tumor makes it difficult to breathe through the nose and is accompanied by recurrent nosebleeds, the patient should be advised to remove it.

 

 

A 30-year-old patient consulted a doctor about the presence of a node in the left mammary gland, which she first discovered about 2 years ago. The node grows slowly. When viewed in the upper outer quadrant of the gland, palpation determines a volumetric mass, rounded up to 2 cm in diameter, dense, slightly painful, with a smooth surface. The skin on it is not changed, it is mobile. Axillary lymph nodes are not enlarged.

What is your presumptive diagnosis and recommendations?

The patient, most likely, has nodular mastopathy. This form of dyshormonal hyperplasia of the mammary gland is dangerous because it can turn into cancer. Therefore, a woman should be strongly advised to promptly treat her surgery. In this case, the sector of the breast is removed and an emergency histological examination is performed. Before the operation, it is imperative to warn the patient about a possible expansion of the volume of the operation, depending on the results of the histological examination of the drug.

 

 

A 60-year-old patient was admitted to the hospital with complaints of persistent constipation lasting up to 3 days. The appearance of stool is noted only after taking laxatives. Regularly, after the act of defecation, traces of fresh blood are found on the feces. Clinical examination revealed no pathologies. A digital examination of the rectum was not informative. Complete blood count: erythrocytes – 3×10 / l, hemoglobin – 100 g / l, ESR – 21mm / h. You suspect that the patient has a tumor in the distal colon. What special research methods do you use to verify the diagnosis?

In case of suspicion of the presence of a colon tumor from special examination methods, it is necessary to perform sigmoidoscopy (fibrocolonoscopy) and irrigoscopy. With endoscopic detection of a tumor, its biopsy is performed, followed by a histological examination of the biopsy specimen.

 

 

A 58-year-old patient came to you with complaints of weakness, feeling of heaviness in the epigastrium, lack of appetite, belching, sometimes vomiting of food eaten, aversion to meat products. Over the past 3 months I have lost 10 kg in weight. When examining a patient with low nutrition. The skin is pale. The abdomen is soft, moderately painful in the epigastrium. Peripheral lymph nodes are not palpable.

What is your presumptive diagnosis and examination tactics?

The patient should be suspected of having stomach cancer. In order to clarify the diagnosis, fibrogastroduodenoscopy, fluoroscopy of the stomach, lungs, ultrasound examination of the liver, digital examination of the rectum are performed.

 

 

A 70-year-old man came to see a therapist complaining of intermittent cough, coughing up sputum with bloody staining, weakness, rapid fatigue. Considers himself ill for the last 2 months. Smokes since the age of 14. On examination, there is a slight pallor of the skin. With chest percussion, a pulmonary sound is detected over both lungs. Scattered dry and moist rales are heard over the left lung.

What is your presumptive diagnosis and examination tactics?

The patient cannot exclude cancer of the left lung. To clarify the diagnosis, it is necessary to do a general analysis of blood and urine, examine sputum for atypical cells and tubercle bacilli, perform electrocardiography, fluoroscopy of the lungs, and, if necessary, tomography of the lungs and bronchoscopy.

 

 

PLASTIC HERURGY AND TRANSPLATOLOGY

Arriving on a call to the scene, you found that the victim’s right hand had got into the machine and that a traumatic amputation of the forearm occurred at the level of the middle third. With the other hand, he holds the compressed limb stump. Blood flows from the wound.

Your actions?

Immediately, it is necessary to temporarily stop the bleeding from the wound by applying a hemostatic tourniquet on the shoulder, apply an aseptic bandage to the stump, and inject pain relievers. The amputated limb should be wrapped in a sterile napkin, placed in a cellophane bag or wrapped in oilcloth, overlaid with ice and taken with the victim to the vascular microsurgery center, where organ replantation is possible.

 

 

A patient was delivered to the surgical department from the scene of the road accident. The right thigh is smashed in the upper third. Feet and lower leg pale, cold to the touch. The popliteal artery pulse is not detected. The patient was taken to the operating room. A crush of the femoral artery was found for 12 cm. What will you do to restore blood circulation in the limb?

In order to restore blood circulation in the limb with such a vessel defect, it is necessary to perform autovenous vascular plasty with a segment of the great saphenous vein after its reversal. If you do not know the technique of vascular grafting, you need to perform a temporary vessel bypass and call a vascular surgeon.

 

 

After 4 degree frostbite, the victim underwent amputation of 2-5 fingers of the right hand. He asked you to “do something to improve the brush function.” How can you help the patient?

In this case, the function of the hand can be improved by autotransplantation of the toe from the foot to the stump of the hand, which should be recommended to the patient.

 

 

The victim’s hand fell under a hot press, resulting in a deep burn on the back of the hand, exposing the tendons and bones.

What type of plastic do you use to maintain brush function?

The optimal solution in this situation is the Italian plastic “from the abdomen to the brush”.

 

 

The ball has atherosclerotic occlusion of the middle segment of the femoral artery. The diagnosis was verified using contrast angiography. What is the method of surgical treatment. Will you suggest to the patient?

In this case, it is possible to propose bypass shunting of the vessel with a Teflon braided corrugated vascular prosthesis (explantation) or a reversed segment of the patient’s great saphenous vein.

 

 

A patient with extensive deep burns has a sharp deterioration in his general condition. The phenomena of burn exhaustion are increasing. Intensive infusion therapy, parenteral nutrition are carried out, but the severity of the condition does not allow autodermoplasty. What will you do in this case?

In such a case, the burn wounds can be temporarily closed with cadaveric skin allografts, brefoskin, pig skin xenografts, or synthetic wound dressing.

 

 

A patient with aplastic anemia underwent bone marrow transplantation. What steps will you take to prevent graft rejection?

In order to prevent graft rejection, prior to surgery, it is necessary to type the tissues of the donor and recipient by antigenic structure and determine their histological compatibility.

In the postoperative period, immuno-depressive therapy is carried out.

 

 

After extirpation of the thyroid gland for cancer in the postoperative period, a patient developed cramps in the limbs and twitching of the facial muscles. What is your diagnosis and treatment tactics?

The patient has hypoparathyroidism, which has developed in connection with the removal of the parathyroid glands. This complication occurs if the level of calcium in the blood decreases to 1.25-1.75 mmol / L, mainly after thyroidectomy.

Treatment consists of intravenous administration of 10-15 ml of 10% calcium chloride solution (if necessary, up to 3-4 times a day). Dihydrotachisterol 2 mg orally after 6 hours has proven itself well. In the future, this drug in a maintenance dose of 2 mg per day is used to prevent attacks.

If conservative treatment is ineffective, the patient should be advised to transplant the thyroid-parathyroid complex.

 

 

SURGERY. PREV. – AND POSTOPERATIVE PERIODS.

An 80-year-old patient was admitted to the department. The surgeon on duty examined her, established the presence of a strangulated right-sided femoral hernia, and suggested an emergency operation. The patient categorically refused, referring to the fact that “it will pass, but she may not be able to endure the operation.”

What should the surgeon on duty do in this case?

The surgeon has no right to operate without the patient’s consent. At the same time, in this case, an emergency surgical intervention is required. Therefore, the surgeon must make every effort to convince the patient of the need for it. It is necessary to lucidly explain to the patient the danger of delaying the operation, the possible adverse consequences of late surgery. The relatives of the patient should be informed, and their help should be sought. The head of the department and even the hospital administration should be notified of the current situation.

 

 

A 13-year-old boy admitted to the surgery department complains of abdominal pain for 12 hours, dry mouth, chills. The child was examined by a ward doctor, diagnosed with acute appendicitis. The patient gave his consent to the proposed operation, about which his parents were informed, and the surgeon began to prepare for the operation. Are the actions of the surgeon legally competent?

In the legal aspect, the actions of the surgeon are incompetent. Surgical interventions for children under 14 years old can be performed only with the consent of the parents or guardian.

 

 

The patient was admitted to the neurosurgical department in an unconscious state with a diagnosis of severe closed craniocerebral trauma, fracture of the right parietal bone, intracranial hematoma, and compression of the brain. The surgeon on duty examined the patient and ordered to immediately prepare him for surgery. What about the patient’s consent to the operation?

In this case, the victim is shown an emergency operation for health reasons. But since the patient is unconscious, and the delay in the operation threatens with death, consent to the operation is not required from either the victim or his relatives.

 

 

A 52-year-old woman of normal physique was admitted to the surgical department with complaints of pain in the right iliac region 12 hours after the onset of the disease, examination by the surgeon on duty was diagnosed with appendicitis. The patient was offered an operation, to which the patient agreed, but on condition that it was performed under local anesthesia.

What should the surgeon on duty do?

First of all, the surgeon on duty is obliged to find out the reasons for the patient’s refusal to be operated on under anesthesia, explaining the advantages of the latter. But if the patient continues to insist on her own, the surgeon must operate on her under local anesthesia.

 

 

Patient 49 years old, with chronic. calculous cholecystitis, accompanied by frequent attacks of epigastric pain in the right hypochondrium, prepared for surgery. But in the morning, on the day of the operation, she learns that the ward doctor will operate on her. The patient demanded to be operated on by any surgeon other than the ward, citing bad dreams.

You are acting as the manager. How to be in this case?

The head of the department should talk with the patient in order to resolve the conflict situation and, if possible, meet her wishes by appointing to operate another surgeon, or perform the operation himself.

 

 

The surgeon, operating on a 36-year-old patient for a reducible acquired umbilical hernia, removed the navel without obtaining her consent before the operation. Are the actions of the surgeon competent?

Even before the operation, the operating surgeon had to obtain the patient’s consent to a possible excision of the navel, otherwise the removal of the navel is illegal. An alternative to this is the formation of an “artificial navel” in the form of local retraction of the skin, fixed to the aponeurosis.

 

A 76-year-old patient was admitted to the department with cramping abdominal pain, stool retention and non-evacuation of gas for 2 days. Diagnosed with acute intestinal obstruction. During an operation performed on emergency indications, it was found that the cause of the obstruction is a tumor of the upper ampullar rectum, invading pelvic tissue. An unnatural anus was imposed, although the possibility of such an outcome, the patient’s surgical intervention before the operation was not informed. Are the actions of the surgeon competent?

Such palliative intervention is performed only to save the patient’s life, but does not cure him. In the lobby of the patient’s grave condition, unjustified radicalism due to the expansion of the volume of the operation, in order to remove the primary tumor at any cost and restore the natural passage through the intestines, is dangerous with a lethal outcome.

In this case, the volume of the transaction is selected correctly and is eligible. However, an experienced surgeon, in order to avoid a conflict situation, already before the operation, could have foreseen the possibility of such an outcome of the surgical intervention and psychologically prepare the patient for its consequences.

 

 

A 49-year-old patient was admitted to the clinic with complaints of persistent epigastric pain, lack of appetite, aversion to meat, weakness. Endoscopic examination of the stomach along the lesser curvature in the upper third of it revealed a callous ulcer up to 2 cm in diameter with a necrotic bottom. Microscopic examination of a biopsy specimen from an ulcer revealed cancer cells. Additional examination revealed no distant metastases.

What will be your tactics? Should the patient be told the true diagnosis?

The patient is shown an urgent operation: extirpation of the stomach.

When offering a patient surgical treatment, for deoncological reasons, one should not tell him the true diagnosis. And at the same time, the reasoning for the need for surgical treatment must be so convincing that the patient has no doubts about the correctness and urgency of the proposed treatment. The true nature of this disease must be reported to the next of kin.

 

 

A 52-year-old patient was admitted to the emergency department with complaints of general weakness, aching epigastric pain. For 3 days there was a tarry stool. For about 10 years he has been suffering from duodenal ulcer.

What about the patient? What should be the type of sanitization, mode of transportation and urgent diagnostic tests?

A patient has a duodenal ulcer complicated by bleeding. Only partial sanitization of the patient is carried out.

According to emergency indications, a general analysis of blood and urine is performed, the blood group and Rh affiliation are determined, fibroesophagogastroduodenoscopy is performed and the patient is transported on a gurney to the surgical department.

 

 

A 26-year-old patient was admitted to the surgical department with a diagnosis of acute appendicitis. I ate food 1.5 hours ago. The chair was a day ago. The clinic is beyond doubt. An emergency operation is indicated. How do you prepare the gastrointestinal tract for surgery?

Since the patient is indicated for an emergency operation, but the day before he was eating, it is necessary to insert a thick probe into the stomach and suck the contents. Any bowel preparation is not required in this case.

 

 

An 86-year-old patient was admitted to the clinic with complaints of severe pain in the abdomen, which appeared suddenly a day ago, “like a dagger strike in the stomach.” For about 20 years he has been suffering from gastritis and 12 duodenal ulcer. On examination, the abdomen is board-like tense, does not participate in the act of breathing, sharply painful in all parts, more in the epigastrium. Shchetkin-Blumberg’s symptom is positive. Peristalsis is not audible. On the survey radiograph, free gas under the domes of the diaphragm is not detected.

What happened to the patient? Does the x-ray result exclude? Your suggestion. How can you confirm your diagnosis?

The patient has a clinical picture of perforated duodenal ulcer. The absence of a “sickle of gas” under the domes of the diaphragm during X-ray examination in a sitting position of the patient does not exclude the perforation of the ulcer. The diagnosis can be confirmed by repeated X-ray examination after pumping air through a probe into the stomach and duodenum.

 

 

An 18-year-old patient with a penetrating wound in the left hypochondrium was delivered to the emergency room by an ambulance. On examination, the skin is pale, the pupils are wide, inhibited, the pulse is 116 beats per minute, the blood pressure is 80/40 mm Hg. Art., blood flows moderately from the wound, a dull percussion sound is determined in the sloping places of the abdomen.

What is your diagnosis and action?

The victim has a penetrating wound of the abdomen, increasing hemoperitoneum, shock of the II degree. It must be transported immediately, bypassing the ward, directly to the operating room, where, against the background of parallel anti-shock measures, an emergency laparotomy is performed and the final hemostasis is performed, depending on the nature of the damage. Any preoperative preparation and delay in the operation in this case are dangerous with death.

 

 

Patient M., 75 years old, 15 minutes after an operation performed under anesthesia for acute appendicitis, turned blue. Respiration is rare, intermittent. What complication of the early postoperative period did the patient develop? Your actions?

Most likely, after the operation, the patient developed vomiting with “mute” regurgitation of vomit in the upper respiratory tract or oropharyngeal obstruction due to retraction of the tongue and lower jaw, which entailed mechanical asphyxia. Help must be provided immediately. With a mouth dilator, you need to open your mouth, remove your tongue with a tongue holder, put in an air duct. When the upper respiratory tract is obstructed with vomit, they are mechanically removed from the pharynx cavity and aspiration of electric suction from the upper respiratory tract.

 

 

Patient O., 45 years old, operated on for a penetrating wound of the chest with damage to the Right lung, developed respiratory failure by the end of the first day. In the position of the patient sitting percussion in the lower parts of the chest, a dull sound is determined, breathing is not heard here. What kind of complication do you suspect? What will be your actions?

The patient should be suspected of right-sided hemothorax. It is necessary to immediately perform a chest X-ray in a sitting position of the patient and, if the diagnosis is confirmed, puncture the chest with X-ray control the next day. For the patient, it is necessary to establish dynamic observation of the medical staff on duty.

 

 

Patient L., 58 years old, for peptic ulcer disease performed resection of 2/3 of the stomach according to Hofmeister-Finsterer. 18 hours after the operation, the patient’s condition worsened: the pain in the epigastrium increased, the abdomen was swollen, hiccups appeared, and difficulty breathing. Single peristaltic noises are heard.

What complication did the patient develop? Your actions?

After gastric resection, a patient developed intestinal paresis. It is necessary to aspirate the gastric contents through a nasogastric tube. It is advisable to leave the probe in the stomach for a longer period until the paresis is stopped. In addition, the patient is shown paranfral novocaine blockade, epidural anesthesia. Medication stimulation (proserin, pituitrin, hypertonic sodium chloride solution, carbocholy, sorbitol, etc.) is prescribed taking into account the imposition of anastomoses and the time elapsed after the operation. All these activities should be carried out against the background of the regulation of water-electrolyte and protein balance.

 

 

Patient C, 70 years old, was operated on for a strangulated right-sided inguinal hernia. 20 hours have passed since the operation. The patient cannot urinate on his own.

What complication did the patient have? What help will you give him?

The patient developed acute urinary retention after the operation.

The bladder should be catheterized with a rubber or metal catheter. The appointment of diuretics in order to relieve urinary retention in this case is contraindicated.

 

 

Patient N., 59 years old, on the seventh day after extirpation of the uterus suddenly developed shortness of breath, cyanosis of the face and shoulder girdle, pain behind the breastbone. The patient lost consciousness. Respiration is frequent, shallow.

What complication did the patient develop? Your actions?

The postoperative period in the patient was complicated by pulmonary embolism. Resuscitation should be started immediately: tracheal intubation, artificial ventilation, closed heart massage. Under appropriate conditions, it is necessary to carry out emergency thromboembolectomy with obligatory massage of both lungs or “catheterization embolectomy” followed by anticoagulant therapy against the background of mechanical ventilation and general anesthesia.

In partial embolism of the branches of the pulmonary artery with a gradually developing clinical picture, oxygen therapy, fibrinolytic and anticoagulant therapy are indicated.

 

 

When examining a patient who underwent supravaginal amputation of the uterus 5 days ago for purulent endometritis that developed after a criminal abortion, you noticed that the entire bandage on the wound over the past 6 hours suddenly got wet with blood secretion.

The patient’s condition is serious, the abdomen is moderately swollen, painful in the area of ​​the postoperative wound. There is scant hemorrhagic discharge throughout the wound between the seams. What postoperative complication is possible? Your actions?

In the patient, subcutaneous eventration that developed in the early postoperative period cannot be ruled out. It is extremely dangerous in such a situation to “blindly” stitch the allegedly bleeding vessels in the walls of the wound, as it is possible to damage the prolapsed intestine. It is necessary to remove some of the stitches and revise the wound. If the diagnosis is confirmed in the operating room under anesthesia, the wound should be sutured again.

 

 

Patient Sh., 63 years old, under urgent indications made a resection of the rectosigmoid part of the large intestine with an obstructing tumor. A primary end-to-end anastomosis was made. On the 10th day, the postoperative period was complicated by external (open) eventration under a bandage of 25 cm of the small intestine. Your tactics?

The patient is shown an emergency operation. The lost loop of the small intestine should be washed abundantly with a solution of antiseptics with antibiotics, put into the abdominal cavity and the wound should be sutured again.

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