- A 31-year-old-man is brought to the emergency department after being involved in a high-speed motor vehicle collision. The patient’s vehicle crashed into a tree when he fell asleep at the wheel. The patient was restrained, his vehicle sustained severe front-end damage, and the air bags deployed in the vehicle. In the emergency center, his vitals signs were as follows: blood pressure 110/80 mm Hg, pulse 110 bets/min, respiration rate 28 breaths/min, Glasgow Coma Score (GCS) 14. The primary survey revealed a patent airway, diminished breath sounds on the left with exquisite chest wall tenderness, and subcutaneous emphysema. The heart sounds are normal and there is no jugular venous distention. The secondary survey revealed no abdominal tenderness, a stable pelvis, and no extremity abnormalities. A chest radiograph revealed several rib fractures on the left a large pulmonary contusion, a left pneumothorax, and widening of the mediastinal structures.
- What are the most likely diagnoses?
- How would you confirm the diagnosis?
- Argue for or against surgical intervention based on your most likely diagnoses.
- A 19-year-old man presents to the hospital 1 hour after sustaining two stab wounds during an altercation. On examination, the patient appears intoxicated and grimaces during manipulation of the wounds. His temperature is 36.8 C, pulse rate 86 beats/min, blood pressure 128/80 mm Hg, and respiratory rate 22 breaths/min. A thorough physical examination reveals two stab wounds. One wound is located at the anterior axillary line, 1 cm above the left costal margin; the second wound is located 4 cm left of the umbilicus. There is no active bleeding form either wound site. The breath sounds are present and equal bilaterally. The abdomen is tender only in the vicinity of the injuries. The patient claims that the knife used in the attack was approximately 5 in (12.7 cm) in length.
- What is your next step?
- What are the potential injuries?
- Outline your medical/surgical approach to penetrating abdominal trauma specifically commenting on both primary and secondary survey.
- A 33-year-old male roofer fell approximately 15-feet from a ladder while working. During the evaluation at the hospital, he was found to have a closed fracture of the right femur, a fracture of the right radius and ulna, and soft tissue contusions and abrasions. The patient underwent open reduction and internal fixation (ORIF) of his femur and external fixation of his forearm without apparent complications. On post-operative day (POD) 2, he began to complain of difficulty in breathing. On physical examination, his temperature is found to be 38.4 C, pulse rate 120 beats/min, blood pressure 148/86 mm Hg, respiratory rate 34 breaths/min, and Glasgow Coma Score (GCS) 15. The patient appears anxious and complains of difficulty breathing but is without chest pain. Auscultation of the chest revels diminished breath sounds bilaterally with scattered rhonchi. The results of a cardiac examination are unremarkable. The abdomen is nondistended and nontender. Examination of the extremities reveals postinjury soft tissue swelling. Laboratory studies reveal the following: WBC 16,000/mm3, hemoglobin 10.8 g/dL, platelet count 185,000/mm3. Arterial blood gas studies reveal pH 7.4, PaO2 55 mm Hg, PaCo2 40 mm Hg, an dHCO3 24 mEq/L. A CXR reveals bilateral non-segmental infiltrates and no effusion or pneumothorax.
- What are your next steps?
- What are your top 6 differential diagnosis?
- Outline your medical/surgical approach to postoperative acute respiratory insufficiency.
- A 74-year-old female recently diagnosed with colon cancer is admitted for changes in bowel/bladder function; otherwise no significant PMHX. Pre-operative blood work grossly WNL. Pre-operative vital signs were: weight 60 kg, BP 124/62 mm Hg, HR 84 beats/min, RR 20 breaths/min, T 98.4 F. A left hemi-colectomy is performed with curative intent. Postop, the patient is stabilized in the PACU then taken to a med-surg unit. Upon transfer to the floor vitals are stable and the patient is afebrile. Currently on 0.9% NS for maintenance fluids at 100ml/hr., an NG tube to intermittent suction for post-operative ileus, patient currently NPO, a Foley catheter and one JP drain in place, and a midline abdominal dressing that is D/I (dry and intact).
You are the surgical PA caring for this patient. Her POD1 vitals as follows: weight 60 kg, BP 100/60 mm Hg, HR 104 beats/min, RR 24 breaths/min, T 100.9 F orally. It is currently 0700, the patient is A&OX3; her color is pale. The NG tube is draining brownish-green mucous, abdominal dressing is D/I, JP with serosanguinous drainage, and maintenance fluids of 0.9% NS remain at 100ml/hr.
24-hr events: The patient says, “I’m so tired, I feel so nauseous, my skin feels hot to touch, and it hurts to move.”
Answer the following questions below regarding the case outlined in question #4
- What would you do first with this patient? List 5 priority interventions you would implement at this time.
The nurse tells you that when she got the patient out of bed this morning per your OOB (out of bed) order the patient experienced dizziness: BP at the time was 90/64 mm Hg, HR 114 beats per minute, and the urine output has been 70 ml since 0600.
- In reference to the new clinical information provided by the nurse, what could be happening to the patient? Provide evidence-based support for your conclusions.
- What would you do first in this situation?
Labs trends: pre-admission vs. POD1
rbc 4.3 à rbc 3.29
wbc 8,000 à wbc 13,000
neutrophils 60% à neutrophils 60%
hgb 12.5 à hgb 9.2
hct 37.5 à hct 48.8
bun 16 à bun 35
cr 0.8 à cr 1.0
serum osmo 280 m/osmo/l à serum osmo 345 m/osmo/l
spec. gravity 1.024 à spec. gravity 1.034
- List six differential diagnosis based on your initial POD1 assessment. Justify each differential diagnosis with evidence-based reasoning.
- Regarding symptom management, what medications would you administer to this patient? List medication class, route, dose, frequency, and indication.
- Based on provided lab values, what could be happening to this patient? Address each lab value that is abnormal and support your conclusions.
- What specific orders would you write in your progress note to appropriately evaluate and manage this patient?
- Based on evidence to achieve positive surgical outcomes, what other issues will you address in the subsequent days in taking care of this patient to prevent complications?
