An 80-year-old male had knee replacement surgery this morning. You are called by the nursing staff late at night because he had climbed out of bed and was found on the floor by a nurse. He began sobbing, saying that his mother was hit by a freight train when he was a child.
The patient’s regular medications include atorvastatin (Lipitor), metoprolol (Lopressor), and hydrochlorothiazide, as well as a variety of medications for knee pain. A retired banker, he now volunteers as a financial manager for several local charities. He had a negative stress test before the elective surgery. The operation was done under combined general and epidural anesthesia, and postoperative pain has been treated with morphine via patient-controlled analgesia.
Which one of the following is the most likely diagnosis?
Correct Answer B: This patient has postoperative delirium, a condition that usually has multiple contributing factors. In this case these could include: age, general anesthesia, and perhaps prolonged tourniquet time. The patient has a disturbance of perception, loss of judgment, and change in mood.
Although the patient’s mood is depressed at present, the problem is labile and acute in nature, rather than being chronic like major depression. A patient may become delirious with a stroke, but the picture is usually dominated by deficits of function. Morphine contributes to delirium, but overdose is another syndrome entirely, presenting with hypotension, respiratory depression, and somnolence.
The use of epidural anesthesia may raise the risk of meningitis, but this is very rare, and is associated with prolonged use of an epidural catheter. Meningitis may produce delirium, but would normally cause signs of sepsis, headache, and neck stiffness.
A 72-year-old Hispanic female with moderately severe Alzheimer’s disease is hospitalized for treatment of a fracture of the left humerus. The first night after admission she becomes confused and agitated.
The most appropriate management at this point is which one of the following?
Correct Answer E: Delirium is a frequent complication of hospital admission in older patients, especially those with preexisting dementia. Orientation and reassurance in a quiet environment will usually be effective in treating the confusion and agitation, once serious causes of the delirium have been ruled out. Benzodiazepines and meperidine have been reported to cause delirium. Physical restraints and restrictive environments (e.g., intensive-care units) can predispose to delirium and are best avoided if possible.
A 61-year-old man post-operative, continues to bleed despite 10 units of blood transfusion.
What is the most likely cause of the continued bleeding?
Correct Answer B:
Giving large amounts of blood must be done with caution. The potential complications are:
This patients continued bleeding can be attributed to dilutional thrombocytopenia. He does not have enough platelets to form a normal clotting response after surgery.
A patient post-operatively continues to bleed despite 10 units of packed RBC transfusion.
What is the most likely cause?
Correct Answer C: There are several adverse effects associated with massive transfusion, and dilutional thrombocytopenia is known as one of the major adverse effects. Dilutional thrombocytopenia is caused by platelet loss out of the body and platelet dilution with replaced red cells and crystalloids. To treat the patient with dilutional thrombocytopenia, platelet count is very helpful to decide when to start platelet transfusion.
The most common cause of a Fistula-in-ano is:
Correct Answer A: An anorectal fistula is a tube like tract with one opening in the anal canal and the other usually in the perianal skin. See picture:
The four major categories of fistula in ano (left side of drawings) and the usual operative procedure to correct the fistula (right side of drawings). A. Intersphincteric fistula with simple low tract. B. Uncomplicated transsphincteric fistula. C. Uncomplicated suprasphincteric fistula. D. Extrasphincteric fistula secondary to anal fistula.
Fistula-in-ano is nearly always caused by a previous anorectal/perirectal abscess. Anal canal glands situated at the dentate line afford a path for infecting organisms to reach the intramuscular spaces. Other fistulae develop secondary to trauma, Crohn disease, anal fissures, carcinoma, radiation therapy, actinomycoses, tuberculosis, and chlamydial infections.
A history of recurrent abscess followed by intermittent or constant discharge is usual. Discharge material is purulent, serosanguineous, or both. Pain may be present if there is infection. On inspection, one or more secondary openings can be seen. A cordlike tract can often be palpated. Diagnosis is by examination. Sigmoidoscopy should follow. Treatment is via surgery.
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