case presentation 3

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CASE PRESENTATIONCASE PRESENTATION

(21.07.08)(21.07.08)

DR. SURRENDAR DAWANIDR. SURRENDAR DAWANI

T.R.M.OT.R.M.ODEPT OF GENERAL SURGERYDEPT OF GENERAL SURGERY

WARD 03WARD 03



CASE 01CASE 01

40yrs old male40yrs old male

H/O grenade blast injury due pellets fromH/O grenade blast injury due pellets from

the exploded hand grenadethe exploded hand grenade Arrived in E.R approx within 30 mins of Arrived in E.R approx within 30 mins of

the eventthe event

C/O:C/O: PAIN IN CHEST (LT)PAIN IN CHEST (LT)PAIN IN ABDOMEN (LT)PAIN IN ABDOMEN (LT)

PAIN IN RT LEGPAIN IN RT LEG



CASE 01CASE 01

INITIAL ASSESSMENT :INITIAL ASSESSMENT :

GCS 15/15GCS 15/15

Airways clear, conversing fluently and clearly Airways clear, conversing fluently and clearly

Moderately labored breathing, rapid and shallowModerately labored breathing, rapid and shallow

Dec. movement in lt chest, asymmetricalDec. movement in lt chest, asymmetrical

movement, single irregularly circular wound 1.5movement, single irregularly circular wound 1.5

mm in 3mm in 3rdrd

ICS, midICS, mid--axillary line,minimal oozing,axillary line,minimal oozing,moderate tenderness all over lt chest, dullness in ltmoderate tenderness all over lt chest, dullness in lt

lower zone, dec breath sounds in lt lower zonelower zone, dec breath sounds in lt lower zone

VITALSVITALS: 130b/min, 90/60, 30br/min: 130b/min, 90/60, 30br/min



Case 01Case 01 ABDO MEN : ABDO MEN : moving, non distended, multiple pellet puncturedmoving, non distended, multiple pellet punctured

wounds all over,wounds all over,

1)1) R.H.C,2cms below & lateral to R.H.CR.H.C,2cms below & lateral to R.H.C

2)2) 2cms lateral to umblicus,2cms lateral to umblicus,

3)3) lt inguinal region 4cms above & lateral to symphysis pubislt inguinal region 4cms above & lateral to symphysis pubis

Soft, mildSoft, mild--moderate tenderness in lt paraumblical region,moderate tenderness in lt paraumblical region,

Gut sounds audibleGut sounds audible

**2 pellet injuries in rt leg, 4 inches distal to rt knee jt**2 pellet injuries in rt leg, 4 inches distal to rt knee jt

**brusing and laceration in lt upper arm approx midway**brusing and laceration in lt upper arm approx midway

between shoulder and elbow jtbetween shoulder and elbow jt



CASE 01CASE 01TREATMENT :TREATMENT :

2 large bore I.V lines.2 large bore I.V lines.

I.V fluids, I.V plasma colloids bolusI.V fluids, I.V plasma colloids bolus

Blood sent for urgent grouping & cross match, 4 Blood sent for urgent grouping & cross match, 4 pints Whole blood arranged.pints Whole blood arranged.

3 pints transfused for acute resuscitation3 pints transfused for acute resuscitation

Catheter passed by dept of Urology, revealing clear Catheter passed by dept of Urology, revealing clear

urineurine N.G passed, 150cc hemorrhagic gastric contentsN.G passed, 150cc hemorrhagic gastric contents

aspirated manually and drain bag attachedaspirated manually and drain bag attached

I.V antibiotic cover and analgesics givenI.V antibiotic cover and analgesics given



CXRCXR: no significant findings: no significant findings

XX--Ray ABDRay ABD: single 0.5 mm irregular shaped: single 0.5 mm irregular shaped

radio opaque shadow seen below lt hemiradio opaque shadow seen below lt hemi--

diaphragm, no signs of intradiaphragm, no signs of intra--peritoneal injuryperitoneal injuryseenseen

XX--Ray PelvisRay Pelvis: single radio: single radio--opaque shadowopaque shadow

seen in pelvic cavity.seen in pelvic cavity.



Case 01Case 01

All wounds cleaned and dressing done All wounds cleaned and dressing done

Chest examined and wound closed by deptChest examined and wound closed by dept

of thoracic surgery. No thoracostomyof thoracic surgery. No thoracostomy

advisedadvised

After 2hrs of aggressive resuscitation and After 2hrs of aggressive resuscitation and

close monitoring, pt shifted to radiology for close monitoring, pt shifted to radiology for

CT scan Chest & AbdomenCT scan Chest & Abdomen



Case 01Case 01OP ERATIVE FINDINGS :OP ERATIVE FINDINGS :

200ml blood drained from the cavity.200ml blood drained from the cavity.

A perforation 2.5 ft from D.J junction and 2 A perforation 2.5 ft from D.J junction and 2ndnd

perforation 3cms distal to first, both approx 0.5 mmperforation 3cms distal to first, both approx 0.5 mmin diameter in diameter-------- primary repair doneprimary repair done

Single perforation, 1cm in diameter, lesser Single perforation, 1cm in diameter, lesser

curvature of stomachcurvature of stomach------ primary repair doneprimary repair done

A single pellet was retrieved from jejunum A single pellet was retrieved from jejunum

THORACOSTOMY tube placed in lt chest cavity byTHORACOSTOMY tube placed in lt chest cavity by

dept of thoracic surgerydept of thoracic surgery



Case 01Case 01

PO ST PO ST- - OP:OP:

NPO till further ordersNPO till further orders

B.P TPR monitoring ½ hrlyB.P TPR monitoring ½ hrly Strict I.O chartingStrict I.O charting

Monitoring of chest tube and drainMonitoring of chest tube and drain

I.V fluidsI.V fluids I.V antibioticsI.V antibiotics

Injectable AnalgesicsInjectable Analgesics



CASE 02CASE 02

20yrs old male, no known co20yrs old male, no known co--morbidsmorbids

C/O:C/O: Absolute constipation Absolute constipation------------since nightsince night

Abdominal distension Abdominal distension------------since nightsince night

O/ E :O/ E : 110b/min, 110/70, 20/min, 18br/min110b/min, 110/70, 20/min, 18br/min

Moderately dehydratedModerately dehydrated

ABDO MEN : ABDO MEN : central distension, mildy tense,central distension, mildy tense,

diffusely tender, hyper diffusely tender, hyper--resonant, G/S not audibleresonant, G/S not audibleD.R.ED.R.E: empty rectum, but fecal stains on finger : empty rectum, but fecal stains on finger



CASE 02CASE 02

P RE P RE- - OP:OP:

NPO, I.V line passedNPO, I.V line passed

I.V antibioticsI.V antibiotics

I.V fluidsI.V fluids

N/G passed and drained 250cc of green bileN/G passed and drained 250cc of green bile

CatherisedCatherised± ± <100cc dark conc urine<100cc dark conc urine Labs sentLabs sent



Case 02Case 02

HbHb± ± 12.5, TLC12.5, TLC± ± 5.9, PLT5.9, PLT ± ± 259259

UCE within normal limitsUCE within normal limits

Xray Abd (erect)Xray Abd (erect) ± ± dilated jejunum, multiple air fluiddilated jejunum, multiple air fluid

levels.levels.

Xray Abd (supine)Xray Abd (supine) ± ± dilated small boweldilated small bowel

P R O VISI O NAL DIAGN O SIS :P R O VISI O NAL DIAGN O SIS :INTESTINAL OBSTRUCTION sec toINTESTINAL OBSTRUCTION sec to

TUBERCULOUS ADHESION BANDS TUBERCULOUS ADHESION BANDS



CASE 02CASE 02P ER P ER- - OP:OP:

Markedly distended whole small bowel,Markedly distended whole small bowel,erythematous, thin walled.erythematous, thin walled.

Patent µPatent µVitelloVitello--IntestinalIntestinal¶ duct (last 1cm¶ duct (last 1cmobliterated), 2ft from I.C junction, extending fromobliterated), 2ft from I.C junction, extending fromileum upto umbilicus.ileum upto umbilicus.

Stricture due to adhesions 1cm proximal to ductStricture due to adhesions 1cm proximal to duct------resection anastamosis done,adhesions lysed.resection anastamosis done,adhesions lysed.

Markedly engorged, dilated mesenteric veinsMarkedly engorged, dilated mesenteric veins

Multiple mesenteric lymph nodes markedlyMultiple mesenteric lymph nodes markedlyenlarged, firmenlarged, firm--hardhard------ biopsy takenbiopsy taken



Case 02Case 02PO ST PO ST- - OP:OP:


I/O chartingI/O charting



Injectable analgesicsInjectable analgesics



CASE 03CASE 03 55yrs old female, k/c of APD, no other known co55yrs old female, k/c of APD, no other known co--

morbids, came to E.Rmorbids, came to E.R

C/O:C/O: Abdominal pain Abdominal pain± ± 2 days2 days

Absolute Constipation Absolute Constipation± ± 1 day1 day No h/o recent fever, cholelithiasis or cholecystitis.No h/o recent fever, cholelithiasis or cholecystitis.

H/o Pulmonary T.B in late 1970s,completely treatedH/o Pulmonary T.B in late 1970s,completely treated

H/o Upper G.I endoscopy few months back for APDH/o Upper G.I endoscopy few months back for APDO/ E :O/ E : 130/min, 110/80, 99F, 28br/min, dehydrated130/min, 110/80, 99F, 28br/min, dehydrated



CASE 03CASE 03

ABDO MEN : ABDO MEN : moving minimally with respiration, nonmoving minimally with respiration, non

distended, diffusely tense, tender and guarding,distended, diffusely tense, tender and guarding,

G.S not audibleG.S not audible

D.R.ED.R.E± ± empty rectum, no fecal stainingempty rectum, no fecal stainingRES P, C VS , C NS :RES P, C VS , C NS : NORMALNORMAL

LABS :LABS : HbHb± ± 10.9, TLC10.9, TLC± ± 1.1, S. Amylase1.1, S. Amylase---- 124, UCE12

4, UCEnormalnormal

X X - -ray ABD:ray ABD: no free gas under diaphragmno free gas under diaphragm



CASE 03CASE 03INITIAL DIAGN O SIS :INITIAL DIAGN O SIS :

PERITONITIS sec to HOLLOW VISCUSPERITONITIS sec to HOLLOW VISCUSPERFORATION / ?? D.U. PERFORATIONPERFORATION / ?? D.U. PERFORATION

P RE P RE- - OP:OP:

NPONPO



Analgesics Analgesics N/G drains 350cc of white fluid mixed with greenN/G drains 350cc of white fluid mixed with green

bilebile

CatheterisedCatheterised± ± bag contains 200cc of conc urinebag contains 200cc of conc urine



CASE 03CASE 03

P ER P ER- - OP:OP:

1 ltr of feculent intestinal contents drained from1 ltr of feculent intestinal contents drained from

cavitycavity

Stricture 2ft proximal to I.C junctionStricture 2ft proximal to I.C junction

Perforation approx 1 inch proximal from stricture,Perforation approx 1 inch proximal from stricture,

1cm diameter, necrosed margins1cm diameter, necrosed margins------ resectionresection

anastamosis done.anastamosis done.

** Iatrogenic tear in mesentery, 2.5 ft from I.C** Iatrogenic tear in mesentery, 2.5 ft from I.C

junction, occurred during gut handling. junction, occurred during gut handling.



Case 03Case 03

PO ST PO ST- - OP:OP:


Strict I.O chartingStrict I.O charting I.V fluidsI.V fluids


Analgesics Analgesics



CASE 04CASE 04

30yrs, Male30yrs, Male

C/O:C/O: Pain in Rt lower abd, Fever Pain in Rt lower abd, Fever

O/ E :O/ E : 100 b/min, 100F, tenderness in R.I.F, Marked100 b/min, 100F, tenderness in R.I.F, Markedguarding, G.S audibleguarding, G.S audible

LABS :LABS : TLCTLC-- 15,70015,700

P RE P RE- - OP:OP: NPO, i.v fluids, i.v antibiotics, analgesiaNPO, i.v fluids, i.v antibiotics, analgesia

P ER P ER- - OP:OP: Acute Suppurative Sub Acute Suppurative Sub--HepaticHepatic Appendix Appendix------ Appendectomy done Appendectomy done

DIAGN O SIS :DIAGN O SIS : ACUTE APPENDICITIS ACUTE APPENDICITIS

PO ST PO ST- - OP:OP: I.V fluids, i.v antibiotics, analgesiaI.V fluids, i.v antibiotics, analgesia



CASE 05CASE 05

15yrs, Male15yrs, Male

C/O:C/O: Pain in Rt lower abd,Pain in Rt lower abd,

O/ E :O/ E : 100 b/min, tenderness in R.I.F, Marked100 b/min, tenderness in R.I.F, Marked

guarding, G.S audibleguarding, G.S audible LABS :LABS : TLCTLC-- 5.05.0

P RE P RE- - OP:OP: NPO, i.v fluids, i.v antibiotics, analgesiaNPO, i.v fluids, i.v antibiotics, analgesia

P ER P ER- - OP: OP: Acute Suppurative Pre Acute Suppurative Pre--ileal appendix,ileal appendix,early lump formationearly lump formation------ appendectomy doneappendectomy done

DIAGN O SIS :DIAGN O SIS : ACUTE APPENDICITIS ACUTE APPENDICITIS

PO ST PO ST- - OP:OP: I.V fluids, i.v antibiotics, analgesiaI.V fluids, i.v antibiotics, analgesia



CASE 06CASE 06 26yrs old, female, k/c of Pulmonary T.B, on ATT26yrs old, female, k/c of Pulmonary T.B, on ATT

since 2 months, came to E.Rsince 2 months, came to E.R

C/O:C/O: Abdominal Pain & Distension Abdominal Pain & Distension------ 2 days2 days

Absolute Constipation Absolute Constipation------ 1 day1 day h/o delivery 8 months back, uneventful pregnancy,h/o delivery 8 months back, uneventful pregnancy,

SVD.SVD.

O/ E :O/ E : toxic looking young female, severelytoxic looking young female, severely

dehydrated, emaciated, lying uncomfortably in beddehydrated, emaciated, lying uncomfortably in bed

VITALSVITALS 140b/min, 110/70, 26br/min140b/min, 110/70, 26br/min



CASE 06CASE 06 ABDO MEN : ABDO MEN : moving minimally with resp, centralmoving minimally with resp, central

distension, mildly tender all over, hyper distension, mildly tender all over, hyper--resonant,resonant,NVM, G.S not audible.NVM, G.S not audible.

D.R.E.D.R.E.------ empty rectumempty rectum

CH EST : CH EST : NVB, occasional fine crepts in Rt MiddleNVB, occasional fine crepts in Rt Middlezonezone

LABS:LABS: HbHb± ± 15.2, TLC15.2, TLC± ± 2.5, PLT2.5, PLT± ± 75, U.C.E75, U.C.E± ± NN

** pt was clinically anemic** pt was clinically anemic X X - -ray Abd ray Abd ± ± advised but not done as pt was not fitadvised but not done as pt was not fit

enough to be shifted to xray roomenough to be shifted to xray room

X X - -ray Chest ray Chest± ± multiple cavitations seen in both lungmultiple cavitations seen in both lungfields.fields.



CASE 06CASE 06INITIAL DIAGN O SIS :INITIAL DIAGN O SIS :

ACUTE INTESTINAL OBSTRUCTION ACUTE INTESTINAL OBSTRUCTION

sec to INTESTINAL T.Bsec to INTESTINAL T.B

P RE P RE- - OP:OP:

NPONPO


I.V antibioticsI.V antibiotics Arrange 4 pints whole blood, transfuse 1 pint pre Arrange 4 pints whole blood, transfuse 1 pint pre--opop

N.GN.G± ± 500cc of feculent aspirate,1000cc after 1 hr,500cc of feculent aspirate,1000cc after 1 hr,

CatheterisedCatheterised± ± 100cc of conc dark colored urine100cc of conc dark colored urine



Case 06Case 06 The pt¶s condition gradually deteriorated and wasThe pt¶s condition gradually deteriorated and was

not fit for surgerynot fit for surgery

Family fully counselled regarding pt¶s diagnosis,Family fully counselled regarding pt¶s diagnosis,

condition and prognosiscondition and prognosis

Shifted to ward at 8:00am on Dopamine supportShifted to ward at 8:00am on Dopamine support

Condition further deteriorated through the dayCondition further deteriorated through the day

EXPIREDEXPIRED IN EVENING OF 22/07/08.IN EVENING OF 22/07/08.



THANK YOUTHANK YOU

case presentation 3

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