Pocket Medicine (Pocket Notebook Series)

SURGICAL ISSUES

ABDOMINAL PAIN

Visceral Pain
Anatomic Division	Viscera	Area to Which Pain Referred
Foregut	Esophagus & duodenum	Epigastrium
Midgut	Jejunum to mid-transverse colon	Umbilicus
Hindgut	Mid-transverse colon to rectum	Hypogastrium

Pain due to pancreatitis and nephrolithiasis commonly radiates to the back

Initial evaluation

• History: onset of pain, location, exacerbating/relieving factors

• Assoc. sx: fevers/chills, N/V, Δ in bowel habits (diarrhea/constipation, stool diam. or color, hematochezia, melena), flatus, jaundice, Δ in urine color, Δ in wt, menstrual hx in women

• PMHx: previous incisions or abdominal surgeries; Ob/Gyn hx

• Exam: VS; general posture of Pt; comprehensive abdominal exam looking for signs of peritonitis, which include rebound tenderness and involuntary guarding, abdominal wall rigidity, pain w/ percussion/minimal palpation; presence of hernias; rectal/pelvic

• Labs: CBC, electrolytes, LFTs, amylase/lipase, pregnancy test

• Imaging: depends on suspected etiology, may include RUQ U/S for biliary/hepatic disease, KUB for intestinal obstruction, CT for pancreatitis or intestinal disease. Do not delay resuscitation or surgical consultation for ill Pt while waiting for imaging.

ACUTE ABDOMEN

Definition

• Acute onset abdominal pain that portends need for urgent surgery

Etiologies

• Perforated viscus → peritonitis (perforated ulcer, complicated diverticulitis, trauma)

• Intraperitoneal or retroperitoneal bleed (also see “Acute Aortic Syndromes”)

• Bowel obstruction (adhesions from previous surgeries, malignancies, hernias, volvulus)

• Acute mesenteric ischemia (esp. if AF, low flow states, “pain out of proportion to exam”)

• Mimics: severe pancreatitis can resemble peritonitis; renal colic causes severe abdominal pain but not abdominal rigidity

Initial evaluation

• H&P as above

• Labs as above plus: PT/INR, PTT, lactate, type & screen (crossmatch if active bleeding)

• Imaging: upright CXR/KUB; if stable, CT A/P w/ IV contrast (IV/PO if suspect obstruction)

Initial management

• Immediate surgical consultation for suspected acute abdomen

• NPO, start IV fluids (NS or LR), Foley, NGT placement if obstruction suspected

• Broad spectrum abx if perforation suspected

EXTREMITY EMERGENCIES

Acute limb ischemia (see “Peripheral Artery Disease” for details)

• Definition: sudden ↓ in perfusion causing threat to limb viability

• Eval: detailed vascular exam (incl. pulses & Doppler signals, motor/sensory function); CTA

• Initial management: anticoag for embolism/thrombosis (heparin dose 80 U/kg bolus, then 18 U/kg drip); immediate surgical consultation

Compartment syndrome (Clin Orthop Relat Res 2010;468:940)

• Definition: ↑ intracompartmental pressure w/ compressive closure of venules → ↑ hydrostatic force resulting in further increases in compartment pressure

• Etiologies: orthopedic (fracture), vascular (ischemia-reperfusion), iatrogenic (eg, vascular injury in anticoagulated Pt), soft-tissue injury (eg, prolonged limb compression)

• Clinical manifestations: pain espec. on passive movement, swollen/tense compartment, paraesthesia, pallor, pulselessness, paralysis (late)

• Evaluation: surgical evaluation of compartment pressures; intracompartment pressure >30 or difference between diastolic & intracompartment pressure of >10–30 is diagnostic

• Treatment: fasciotomy

SURGICAL TUBES, DRAINS, WOUNDS

Tracheostomy (Otolaryngol Head Neck Surg 2013;148:6)

• Typically a cuffed tube, which creates a tight seal to facilitate ventilation throughout tube

• Speaking valve (eg, Passy-Muir): 1-way valve that allows inhalation through tube, but exhalation around tube through vocal cords (nb, cuff should not be inflated)

• 1^st routine tube Δ for percutaneously placed tubes should be ~10 d postop; surgically placed tubes can be Δ’d >5 d postop; first Δ should be overseen by experienced person

• Accidental dislodgement: intubate from above (if airway/vent nec & anatomically possible)

w/in 7 d of placement: emergent surgical consultation

>7 d after placement: replace with a similar size tube or smaller

Chest tubes (Eur J Cardiothorac Surg 2011;40:291)

• Inserted for PTX, chest trauma or after thoracic surg for drainage of air/fluid from thoracic cavity. Range from small (8–10 Fr for spont. PTX) to large (28–32 Fr after pulm. resections)

• Connected to 3-chamber chest drainage system:

1^st: collection chamber for pleural fluid

2^nd: water seal chamber used to allow air to exit pleural space on exhalation and prevent air from entering on inhalation

3^rd: suction control chamber which regulates suction transmitted to pleural space

• Monitor for output and presence of air leak (indicated by bubbling in water seal chamber)

• Removal determined by overall daily outputs and absence of air leak

• If accidentally removed or dislodged, tube should be completely removed and an occlusive dressing (eg, 4 × 4 covered w/ Tegaderm or silk tape) should be placed rapidly over site. CXR STAT; new tube should be placed if persistent PTX.

Gastrostomy/jejunostomy tubes (Paediatr Child Health 2011;16:281)

• Placed for tube feedings, hydration, and delivery of medications

• Should not be removed for ≥6–8 wk to allow establishment of mature gastrocutaneous tract

• Obstructed tubes can be cleared by flushing with agents such as carbonated water, meat tenderizer, & pancreatic enzymes. ↓ obstruction by flushing before & after meds and flushing q4–6h when receiving continuous feeds.

• Inadvertent removal: place Foley catheter of similar size or smaller into tract immediately to prevent stoma from closing. Tube then replaced and confirmed via fluoro study.

Suture/staple removal

• Should be done in consultation w/ surgical team; timing depends on location of wound

• Should not be removed if there is evidence of wound separation during removal!

• After removal, wound should be reapproximated w/ Steri-Strips

Decubitus ulcers (J Wound Ostomy Continence Nurs 2012;39:3)

• Sores in dependent areas exposed to repeated pressure (commonly sacrum, heels)

• Risk factors: immobility, poor nutritional status

• Stage I (non-blanchable erythema); Stage II (partial thickness); Stage III (full-thickness skin loss); Stage IV (full-thickness tissue loss)

• Treatment: offload area, air mattress, pillows and/or support boots, nutritional support

• Surgical consultation for debridement of ulcers with necrotic or infected tissue, may require plastic surgical reconstruction for advanced ulcers once clean

MAXIMIZING A SURGICAL CONSULT

• For ill Pt, call surgical consult early, do not wait for labs & imaging results

• If potential surgical emergency, make Pt NPO, start IVF, ✓ coags, type, & screen

• Have appropriate-level MD who knows & has examined Pt call consult

OB/GYN ISSUES

VAGINAL BLEEDING

Bleeding from lower (vulva, vagina, cervix) or upper genital tract (uterus)

Etiologies

• Premenopausal

Not pregnant: menses, lower tract (trauma, STI, cervical dysplasia/cancer), & abnormal uterine bleeding (polyp, adenomyosis, leiomyoma, hyperplasia/cancer, coagulopathy, ovulatory dysfunction, endometrial, & iatrogenic)

Pregnant

1^st trimester: threatened abortion, spont. abortion (missed, incomplete, or complete), ectopic preg, molar preg (partial/complete hydatidiform mole)

2^nd or 3^rd trimester: preterm labor/labor, placenta previa, placental abruption

• Postmenopausal: atrophy, polyp, leiomyoma, endometrial hyperplasia/cancer

History & exam

• Age, menopausal status, gestational age if preg, volume & duration of current bleeding

• If premenopausal: menstrual hx including age of onset, interval between & duration of menses, any assoc. sx & LMP to assess timing of menstrual cycle

• Past Ob/Gyn hx: incl. any structural abnl, STI, & contraception

• Health maint.: Pap smear, HPV screening, domestic violence, anticoag/antiplt meds

• General physical & abdominal exam (incl. tenderness, masses)

• Pelvic exam: external (quantity of bleeding seen on vulva, any lesions, any trauma), speculum exam (quantity of bleeding, cervical os open/close; & if open, dilation, any polyps), & bimanual exam (cervical dilation, uterine size/tenderness, adnexal mass/tenderness)

Laboratory evaluation & imaging

• Urine (rapid test) & serum preg test (βhCG), Hct/hemoglobin

• Pelvic U/S: visualize leiomyoma & if preg, intrauterine preg & placental position to r/o placenta previa/abruption

• If preg & intrauterine preg not seen, must r/o ectopic as life-threatening dx (βHCG > discrim. zone → ? ectopic; if βHCG <discrim. zone → follow βHCG) (JAMA 2013;309:1722)

VAGINAL DISCHARGE

Fluid or mucus from vagina, cervix, or uterus

Etiologies

• Infectious: bacterial vaginosis, candida vulvovaginitis, trichomoniasis

• Noninfectious: physiologic (in preg/non-preg), rupture of membranes, foreign-body rxn

Initial evaluation

• Age, LMP, gestational age if preg or menopausal status

• Discharge quantity, color, consistency, odor, assoc. sx (itchiness, redness, abd/pelvic pain)

• Past Gyn hx: incl. STI and contraception usage (condoms ↓ STI risk)

• Tampon or condom use as risk factors for retained foreign body

• Pelvic exam: external (quantity & quality of discharge on vulva, any lesions), speculum (discharge, appearance of cervix), bimanual (cervical motion tenderness)

• Laboratory: pH of discharge, microscopy (saline & KOH wet mounts), urine preg test

Treatment

• Bacterial vaginosis: oral/vaginal metronidazole or clindamycin

• Candida vulvovaginitis: oral/topical antimycotic medications

• Trichomoniasis: oral metronidazole

ADNEXAL MASS IN NON-PREGNANT WOMAN

Mass arising from ovary, fallopian tube, or surrounding connective tissue

Etiologies

• Ovarian: functional cyst (follicular/corpus luteum), hemorrhagic cyst, endometriomas, ovarian torsion, tubo-ovarian abscess, benign & malignant ovarian tumors

• Fallopian tube: paratubal cyst, hydrosalpinx, ovarian torsion, tubo-ovarian abscess

Initial evaluation

• LMP/menopausal status, assoc. sx of abd/pelvic pain, FHx of gyn cancers

• Abd exam (distension, tenderness, masses), bimanual (uterine or adnexal masses)

• Preg test if premenopausal (if ⊕, then mass likely preg), CA-125 if postmenopausal

• Pelvic U/S (even if mass 1^st identified on CT, because U/S is best modality), U/S appearance of mass important factor to determine risk of malignancy

OPHTHALMIC ISSUES

INITIAL EVALUATION

• Ocular symptom: onset (sudden or progressive) & duration of sx; unilateral vs. bilateral; pain; photophobia; discharge; Δ in near (eg, book) or far (eg, TV across room) vision

• Preexisting ocular conditions, eye meds (incl any Δs), recent h/o ocular surgery, trauma

• Ocular exam: vision (✓ with Pt’s correction [glasses/contacts]) w/ each eye; pupillary exam; EOM; confrontation visual fields (important if suspect CNS problem)

• Overall: VS, immunocomp., s/s of infxn, h/o malig, CNS issues, Δ in meds, CBC, coags

COMMON VISUAL SYMPTOMS

• Fluctuation in vision (ie, blurry): med-induced refractive error (eg, systemic steroids, chemoRx), hyperglycemia, dry eye (common). Visual defect may p/w “blurred vision.” Bilateral: glaucoma (common), homonymous contral. CNS lesion; bitemporal: pituitary, toxic/nutritional. Unilateral: ipsilateral orbital, retinal, or optic nerve lesion.

• Red eye:

Bilateral: viral conjunct. (starts in 1 eye; also w/ lid swelling, discharge); chronic inflammation (dry eyes, rosacea, autoimmune disease)

Unilateral: subconj. hemorrhage, infxn, or inflam (eg, episcleritis, iritis, uveitis, scleritis); acute angle closure (qv). Scleritis & acute angle closure p/w severe pain, H/A, nausea.

• Double vision (diplopia): fixed double vision w/ ophthalmoplegia from orbital process or cranial nerve palsy (III, IV, VI). Transient “diplopia” due to fatigue or sedation.

• Flashing lights/floaters: vitreous detach. (common, benign); retinal detach. (unilateral visual field defect; urgent ophthalmology consult); hemorrhage; intraocular lymphoma

ACUTE VISUAL CHANGES

Etiologies of Acute Vision Loss (italics indicates a/w pain)
	Unilateral	Bilateral
Transient (<24 h, often <1 h)	Ret. art. embolism, impending retinal artery or vein occlusion (amaurosis fugax), vasospasm, carotid disease	Ocular surface dis. (dry eye), bilat. carotid dis., TIA, migraine, high ICP (papilledema)
Prolonged (>24 h)	Retinal art/vein occl, retinal detach., retina/vitreous heme, retinitis, ant. optic neurop./corneal ulcer, GCA, acute angle closure glaucoma	Visual cortex stroke, post. ischemic neuropathy (profound hypotension during surgery), post. reversible enceph. synd., GCA

COMMON OCULAR CONDITIONS (FRONT TO BACK)

• Orbit: orbital cellulitis (fever, proptosis, ↓ EOM; emergent abx, scan, & referral)

• Lids: hordeolum or chalazion (stye); preseptal cellulitis; ptosis (age; Horner’s; CN III palsy: EOM restricted in all directions except laterally (eye is “down & out”), a/w ptosis & mydriasis, seen w/ uncal herniation, aneurysm of post com art., GCA, HTN, DM); incomplete lid closure (CN 7^th palsy)

• Conjunctiva: conjunctivitis (red eye); subconj. hemorrhage (HTN, blood thinner); ocular surface disease (dry eyes); episcleritis/scleritis (deep vessels of sclera)

• Cornea: contact lens-related ulcer; herpetic keratitis/scarring/neurotropic ulcers (CN V paresis); pterygium; keratoconus; corneal dystrophy

• Ant. chamber: iritis (inflam. cells); hyphema (blood, post trauma); hypopyon (inflam./infxn)

• Pupil: Anisocoria (physiologic asymmetry); Horner’s, CN III

• Lens: cataract (age, trauma, medication, radiation, congenital); post cataract surgery infxn

• Vitreous/Retina/Macula: diabetic retinopathy; macular degen; retinal detachment; retinal ± vitreous hemorrhage; retinitis (infectious)

• Optic nerve (CN II): ischemic neuropathy p/w acute unilat. visual loss, altitudinal field defect; a/w GCA; nonarteritic a/w HTN, hyperchol., DM, thrombophilia. Optic neuritis: often p/w unilat. central scotoma, pain w/ EOM, ↑ visual loss over days; a/w demyelinating disease (eg, MS), also seen w/ sarcoidosis & CTD. Optic neuropathy (glaucoma common).

OCULAR EMERGENCIES

• Chemical splash: alkali worse than acid; immediate eye flush; pH 7.3–7.4 normal

• Acute angle closure glaucoma: fixed mid-dilated pupil, corneal edema, high intraocular pressure (typically >50; normal 8–21). Rx w/ topical drops; may require AC tap/laser.

• Penetrating eye injury: protect eye (no patching), IV abx, tetanus, NPO, surgical prep