A mortality due to obstructed inguinal hernia with background aids
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A MORTALITY FOR GENERAL SURGERY – YELLOW TEAM
DR BASSEY AE
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BIODATA
• P.O.• 50 YO• MALE• DRIVER• IDOMA
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P.C.
• ABDOMINAL PAIN x 4/7
• ABDOMINAL SWELLING x 2/7
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HxPC
• 4/7 PRIOR TO PRESENTATION DEVELOPED ABDOMINAL PAIN, UMBILICAL, ACHING, NON-RADIATING, NO KNOWN AGGRAVATING FACTOR, RELIEVED BY VOMITING
• VOMIT – NON-PROJECTILE, NON-BILOUS, NON-BLOODY, OCCURRED AFTER INGESTING FOOD OR FLUID
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HxPC (CONT’D)
• ASSOCIATED FREQUENT LOOSE STOOL, WATERY, NON-MUCOID, NON-BLOODY
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HxPC (CONT’D)
• 2/7 AFTER ONSET OF THESE PROBLEMS, STARTED HAVING PROGRESSIVE ABDOMINAL SWELLING ASSOCIATED WITH THIRST AND ↓URINE AND STOOL OUTPUT
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HxPC (CONT’D)
• NO PRIOR HX OF ABD TRAUMA• NO HX OF ILLNESS XTISED BY HI GRADE FEVER,
HEADACHES, DIARRHOEA• NO HX OF ABD SURGERY• PRIOR TO ONSET, NO HX OF CHANGE IN BOWEL
HABITS, WT LOSS OR HAEMATOCHEZIA • NO HX OSF SWELLINGS IN GROIN OR ANY OTHER
PART OF ABDOMEN THAT APPEAR ON STRAINING OR COUGHING
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HxPC (CONT’D)
• PT TOOK HERBAL MEDICATION FOR HIS PROBLEM BUT HAD NO RESPITE
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SYS REVIEW
• N A D
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PMHX
• KNOWN RVD ON HAART, OFF MEDICATION FOR 2 MONTHS PRIOR TO PRESENTATION
• DGXED 2YRS AGO
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FSHX
• DOESN’T SMOKE OR TAKE ALCOHOL
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EXAMINATION - GENERAL
• MIDDLE AGED MALE• RESTLESS• PALE• DEHYDRATED• ANICTERIC• ACYANOTIC• FEBRILE (T – 38.8C)• NO PEDAL OEDEMA
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ABDOMEN• DISTENDED• MWR• TENSE• TENDER• PN – TYMPANITIC• BS – HYPOACTIVE• 6x4 CM SWELLING IN RT INGUINAL REGION, NO
COUGH IMPULSE, FIRM, TENDER, IRREDUCIBLE• HAD REDUCIBLE SWELLING WITH POSITIVE
COUGH IMPULSE ON LT INGUINAL REGION
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RECTAL EXAM
• EMPTY RECTUM• SLIGHTLY ENLARGED PROSTATE
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CVS
• PR – 124B/M, SMALL VOL• BP – 100/60 MMHG
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CHEST
• DYSPNOIEC• RR – 48C/M
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CNS
• N A D
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PROBLEMS
• SEPSIS• ACUTE INTESTINAL OBSTRUCTION• OBSTRUCTED RIH• REDUCIBLE LIH
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MGT PLAN
• RESUSCITATION WITH R/L VIA 2 WIDE BORE CANNULAE. PT BECAME CALM, VITALS IMPROVED TO PR-90B/M, BP-120/70MMHG
• ANTIBIOTICS – ROCEPHIN, FLAGYL• NG TUBE – 2L BILOUS FLUID• URETHRAL CATHETER PASSED – CONC URINE
INITIALLY THEN DILUTE URINE• NPO
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MGT PLAN (CONT’D)
• FLUID CHART FOR I/O MONITORING• VITAL SIGNS MONITORING• URGENT PCV, E/U/CR, URINALYSIS, CXR, PLAIN
ABD XRAY• SR INFORMED – GXM 2UNITS, FOR
EMERGENCY EXLAP AS SOON AS STABLE
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2ND DAY OF ADMISSION
• PT OBJECTED TO SURGERY AND PREFERRED MEDICATION DESPITE BEING EDUCATED ON THE NATURE OF HIS PROBLEM, THE NEED FOR SURGERY AND THE PERILS OF FURTHER DELAY
• MEANWHILE, INVX RESULTS:• PCV : 17%• E/U/CR : Na – 152, Cl – 127, HCO3 – 12
• NG TUBE EFFLUENCE: 6500ML OVER PAST 17HRS• URINE BAG – DILUTE URINE
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2ND DAY
• RECEIVED 1 UNIT OF BLOOD• 5 UNITS OF BLOOD REQUESTED FOR PRE-OP
TRANSFUSION AND SURGERY• PT STILL REFUSED SURGERY
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3RD DAY
• NG TUBE EFFLUENCE – 800ML OF FAECULENT FLUID
• RECEIVED 2ND UNIT AND HAD 2 EXTRA• PT ALSO CONSENTED TO SURGERY AND WAS
BOOKED FOR EMERGENCY EX-LAP
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INTRA-OP
• RIGHT DIRECT RICHTER HERNIA WITH HERNIATED SMALL BOWEL SEGMENT ISCHAEMIC
• ON APPLICATION OF WARM SALINE PERFUSION IMPROVED AND BOWEL WAS RETURNED
• LEFT SLIDING HERNIA WITH SIGMOID COLON FORMING PART OF HERNIA SAC
• HERNIORRHAPHY WAS PERFORMED ON BOTH SIDES
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POST OP ORDER
• NPO• 3L/DAY, ALT R/L AND D/W• ANTIBIOTICS – LEVOFLOXACIN, FLAGYL• ANALGESIA – PENTAZOCINE• FLUID I/O MONITORING• VITALS MONITORING• TRANSFUSE 2 UNITS IN FIRST 24HRS POST OP
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12HRS PO
• NG TUBE – BILOUS• URINE BAG – DIL URINE• FEBRILE – 38.3-39.7C• PLAN – CT POST OP CARE
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POD 1
• NG TUBE – BILOUS• FEBRILE – 38.3-40C• DEHYDRATED• PR – 82, BP – 110/70• BOWEL SOUNDS – HYPOACTIVE• PLAN: INCREASE FLUID INPUT TO 4L/DAY,
URGENT E/U/CR
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POD 2
• BOWEL MOTIONS RESUMED• FEBRILE – 39.4-40.3C• STARTED TALKING IRRATIONALLY• POST OP PCV – 33%• YET TO DO E/U/CR• PR – 84, BP – 110/60• PLAN – TEPID SPONGING, IM PCM, CHANGE
FLAGYL BRAND, TO RECEIVE 50MMOL KCL/DAY
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POD 3
• STILL FEBRILE: 39.8-40.8C• NG TUBE – SLIGHTLY BILOUS• URINE BAG – DILUTE URINE• NO E/U/CR YET• PR – 100, BP – 110/60• PLAN – URINE M/C/S, BLOOD M/C/S, CT IV
ANTIBIOTICS FOR ANOTHER 48HRS
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POD 3(CONT’D)
• STILL FEBRILE: 40.8C• PLAN – INVITE PHYSICIAN IN CHARGE OF RVD
MGT, FOR POSSIBLE EX-LAP
• PATIENT PASSED AWAY 7HRS AFTER ABOVE REVIEW
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THANK YOU