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DESCRIPTION
???. Dr Tom Hardy SHO General Surgery. 85 yo male. Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis 4/7 increasing RIF Over last 24 hours has developed Nausea and 1 x vomiting Starting to feel unwell PMH – HTN, AF, Angina. Differentials??. Appendicitis - PowerPoint PPT PresentationTRANSCRIPT
DR TOM HARDYSHO GENERAL SURGERY
???
85 yo male
Patient referred from GP – concerned about this gentleman’s pain, ?appendicitis
4/7 increasing RIFOver last 24 hours has developed Nausea and
1 x vomitingStarting to feel unwellPMH – HTN, AF, Angina
Differentials??
AppendicitisBowel Obstruction due to
Hernia Ca Adhesions
PerforationRenal Colic
Plan?
Airway – is it patent?Breathing -
RR 24 O2 saturations 99% on 5litres O2
Circulation – BP 95/54 P 102
Disability – AVPU
Everything else – T 37.1 U/O ?? BM – 6.9
On examination
Cardio – I + II + O
Respiratory - Good air entry
Abdo – V tender RIF, small lump in R groin, red, tender,
no cough impulse, non-reducible Rest of abdomen soft, bowel sounds not present PR – empty rectum
Initial Management
Groups please
Initial investigations/beside
Scans/secondary investigations
Other considerations
Initial Management 1
Bedside – Vital signs Bloods
FBC, LFT, U&E, CRP, Amy, G&S/X-match ABG BM Catheterise/NG Tube IVI NBM
ABG
pH 7.25
pO2 8.5
pCO2 3.8
Glu 6.4
Hb 11.2
Lac 2.5
BE -6.5
HCO3- 14.5
Initial Management 1
Scans AXR? CXR?
CT abdo/pelvis
Extras
Inform theatresInform anaesthetistBooking and consentingECG
Bloods
Hb 10.2 TP 75 Ur 12.7
MCV 94.2 Alb 36 Cre 147
WCC 17.8 Bi 7 Na 138
Neut 14.1 ALT 20 K 3.6
CRP 215 Alk Phos 98
Hernias!
Definition - Protrusion of a tissue through the wall of the cavity
which normally contains it
Reducible – you can put it back in
Irreducible – you can’t
Incarcerated – you can’t put it back in
Strangulated – blood supply cut off
1) Risk factors for developing hernia Smoking, chronic cough, female, heavy lifting, previous
surgery
2) Hernia develops, initially reducible and of no concern
3) If increases in size, may become irreducible
4) Part of bowel/tissue gets trapped leading to irritation, swelling, oedema
5) Increasing size leads to further issues which may compromise blood supply
6) Hernia becomes strangulated, can lead to necrosis as no blood supply and peritonism
Types of Hernia
Inguinal Direct vs Indirect
FemoralIncisional – ummm...through an incisionRichter’s Hernia – one side of bowel wall,
may not be an obstructionUmbilical/paraumbilicalLittre’s hernia
Up-to-date webite, viewed 3/1/12, http://www.uptodate.com/contents/image?imageKey=SURG/27585&topicKey=SURG/3686&source=outline_link&search=femoral hernia&utdPopup=true
Up-to-date webiste, http://www.uptodate.com/contents/image?imageKey=SURG/27584&topicKey=SURG/3686&source=outline_link&search=femoral hernia&utdPopup=true, viewed 3/1/12, hernia anatomy
Surface Anatomy
A: Inferior epigastric artery
B: Femoral nerveC: Femoral arteryD: Femoral veinE is the most
important …THE PUBIC
TUBERCLE
Examination of a Hernia
Examine standing and sittingHow do you assess a lump??SCRoTum
3 x S – Size, Shape, Surface 3 x C – Cough impulse, Colour, Consistency Reducibility 3 x T – Tenderness, Transillumination, Temperature External genetalia!!!
IPE Questions 1
This gentleman has a swelling in his groin, please take a history...
Risk factorsFeatures of a herniaDifferential diagnosis
Don’t forget lymphadenopathy
IPE Questions 2
Examination...
Hernia or Abdomen??
Probably Hernia first, if time/to finish abdomen
IPE Questions
What is a hernia?How to differentiate between direct and
indirectHow to differentiate between inguinal and
femoralHow would you identify the deep inguinal
ring?
Treatment optionsComplications of hernia surgery
Communication in Surgery
Happy
PR not PV!
Sad
Get out of my theatre
Hmmmm
Good job
Angry
Your only fit for psych