Laparoscopy question - Forum

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Lady Surgeon

Laparoscopy question - Ärzteforum

Post#1 »

1. A middle-aged female presents to the ER >1 wk postop laparoscopic oopherectomy (significant adhesions) after > 12 hrs LLQ pain unrelieved by the oral analgesic she had been prescribed postop. Significant fresh abdominal bruising, frequent vomiting, no return from OTC enema at home...SOB, K+ 2.7, and "Looks sick as hell" (according to the paramedic who brought her in and the "2" ER nurses assigned to her).
?What's your Dx:

2. After admission and over the course of a few hours w/ SSE x 2 w/ minimal return has tympanic T100.2, 101.4, ^RR, ^HR, weak pulse and can't get B/P on the Dynamap
? What's your Dx:

Other things I should add to this case study for ER nurses and floor nurses as an exercise in critical thinking so they can communicate effectively w/ the surgeon? What would you dx based on this info and what else would you want to know/order, etc?

Thanks SO much in advance to those of you who are willing to share your knowledge and expertise...:)


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A Doctor

Re: Laparoscopy question - Ärzteforum

Post#2 »

Firstly a hand on the belly might be all one would need to have to make a decision. A decision is sometimes more important than a diagnosis. That is why we are surgeons, not internists. Haematology and 3 views of the abdomen may be helpful, but I don't think many of us would be comfortable making too many comments without a physical exam.

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Surgeon

Re: Laparoscopy question - Ärzteforum

Post#3 »

Sounds like she needs properly resuscitated and then opened - bleeding/sepsis. I would be most concerned that she still has an unrecordable BP despite being in your ER for some hours - its to prevent that situation that one has ERs. While it may be an interesting academic process to guess what precise problem she has, someone presenting with a distended acutely tender abdomen in hypovolaemic/septic shock needs urgent action otherwise the pathologist will be the one to find out all the answers.

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Loit

Re: Laparoscopy question - Ärzteforum

Post#4 »

From item # 1, a patient that sick will have vital signs and physical exam findings that should lead her to be admitted to the part of the facility that handles the sickest patients, typically the intensive care unit. At that point, the aim will be aggressive resuscitation, optimization of the hemodynamics, and getting her ready to move to the OR ASAP.

From item # 2: Obviously things already cascaded to a worse degree of sepsis. Again, aggressive resuscitaion including invasive hemodynamic monitoring, if available, is standard, and get her ready to move to the OR ASAP. At this point the prognosis is getting worse and time is critical.

Your question "what's your diagnosis"? The physiologic diagnosis is sepsis. The cause may be bowel injury, infected intra-abdominal collection, or ischemic entrapped bowel, for a short list.

By the way, was that case a real one? If so, will be interested to know the final diagnosis and outcome.

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surgery

Re: Laparoscopy question - Ärzteforum

Post#5 »

This patient has a colonic perforation until proven otherwise.

सर्जन

Re: Laparoscopy question - Ärzteforum

Post#6 »

Having to approach such a complicated patient,I think that the best is to
call a surgeon, the best available...

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Surgeon

Re: Laparoscopy question - Ärzteforum

Post#7 »

We surgeons stopped playing the DD game (differential diagnosis) early in
our training. Unlike non -surgeons we do not need this crap.
All we want to know is: "does this patient need to go to the OR?" or
"are further tests necessary?"

So at this stage we won't waste time entertaining any DD ; instead, we want
to examine the patient.

Noro

Re: Laparoscopy question - Ärzteforum

Post#8 »

Lady Surgeon wrote:
Other things I should add to this case study for ER nurses and floor nurses as an exercise in critical thinking so they can communicate effectively w/ the surgeon? What would you dx based on this info and what else would you want to know/order, etc?

Thanks SO much in advance to those of you who are willing to share your knowledge and expertise...:)


Yes. .... and I'd just be really glad to have the surgeon come in to
take a look. Nevermind what dx _I_ would entertain.
I don't know that I'd need a dx to communicate effectively with the docs.
Just need to be able to communicate effectively what I am observing in
this patient. "Is there a doctor in the house?"

User avatar
Lady Surgeon

Re: Laparoscopy question - Ärzteforum

Post#9 »

I will most assuredly post a summary of all of the responses I receive on
this most real case...however, I just can't pass up the opportunity to respond
to you in a timely manner. The operating surgeon indeed was called to see the
pt, (since he was inhouse, ER MD felt appropriate to bless that decision). He
responded in his own sweet time, (don't have a clue when that was since he did
not document time pt seen) and we can/may/would assume he did lay upon the
hands and personally examine the pt although is highly questionable that it
could have been the physician's assistant who actually did the exam ( not sure
since he didn't date/time nor sign the assessment). (Did any of you catch the
drift here...you too must document the trivial stuff like time and date?) His
DD was Minimal ileus, based on upright and flatplate (neglected to order a
lateral decub) so he ordered SSE x 2 (soap suds enemas, can you EVEN believe
that) on this poor sick lady. And, by the way, a tympanic T is a temperature
taken tympanically, ie eardrum... common practice these days. It would seem to
me that somewhere one should question a perforation...unfortunately NOT!

Also unfortunately, NO temp was taken in the ER. Nurses couldn't explain that
one...glad to say it wasn't my hospital's ER...we exercise a much higher
standard of care...

Sad to say, many breaches in standard of care...thus making my job much more
critical...educate anyone and everyone on what to look for and what to
document and what to report so the best decisions are made for the good of the
patient..

And I'm so RELIEVED to know there are other nurses on the list...let us all
work together to share our expertise and bring as much healing as
possible...the work of surgeons is an admirable one...my respect to all of
you.

Priya

Re: Laparoscopy question - Ärzteforum

Post#10 »

I would aggressivly and quickly resuscitate this patient and go to
the OR to laparotomy to correct what is probably a colon injury. I
would not have ordered more enemas in the hospital. At the point of
admission, the patient had a good chance of dying of this injury.
This might be a good point to review nursing's (as well as the
surgeon's) discharge instructions post cases like these (lap GYN
cases)--what was the patient warned to contact the hospital or
doctor about. It would have been better if she had come straight
to the hospital instead of trying oral analgesics and enemas at
home for an apparently new pain.

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